OHLIs Unplugged: Resiliency & Wellness

Well, welcome everybody. If I may ask, if you just write in the chat where you're from, that would be awesome. We're looking forward to starting this very, for me, anticipated podcast episode with Dr. Azzam and, as well, my co-host. Yes, here. Hi everyone, where are you all watching or tuning in from? I'm personally in Istanbul. If anyone's in Turkey, could just shoot a message to see how many people are in the same country, and we'll give it one more minute and then we'll begin. I'm coming to you from San Francisco, California, in the US, and I'm here from Chouin Canada. Nice. And CH, I guess we could begin now. We can see the chat. Oh, okay, perfect. Well again, welcome everyone to ?Music?. My name is Parsa, and my co-host here, Yasir, are both part of the OHLI community, which stands for Osmosis Health Leadership Initiative. It's a fantastic program, a very lovely community, with an Osmosis former mo savior, of course, and through these OHLI unplugged episodes, and this being the first one for the year of 2025, we usually unplug from our busy health care curriculum or extracurriculars and want to meet amazing people around the world and have some conversations about different aspects of health care and beyond. Today is definitely no different. Today we're going to talk about resiliency and wellness. Also, for these episodes, we encourage members in the audience to participate, share stories, and ask questions as we like to keep these moments interactive. Absolutely. It's our honor, and it's our honor to introduce our very special guest today, Dr. Rin Azzam. For those who may not know, he's a prominent and respectable educator and psychiatrist whose innovative work has contributed to improving medical education around the whole globe. Dr. Azzam completed his undergraduate degree at University of Rochester and then med school at Medical College in Virginia. Then he did his psych residency at University of California in San Francisco, and he's a professor at three San Francisco Bay Area universities: UCSF, UC Berkeley, and Samuel Merritt University. His dedication to educational development is evidenced from his unique innovations and what many of us students are familiar with now: problem-based learning, simulation-based learning, open educational pedagogy?I don't know how to pronounce that word properly, hope pedagogy?but that's good, open education pedagogy. All these are conducted in health professional schools, bringing them in there. In 2013, Dr. Azzam created the world's first elective course where students had the opportunity to learn how to improve the reliability of publicly available medical information by editing medical articles on Wikipedia, reflecting his commitment to open access knowledge dissemination and making healthcare accessible worldwide. Dr. Azzam also serves as the faculty engagement coordinator at Osmosis, collaborating with faculty from other health professional schools affiliated with the platform to integrate Osmosis education resources into their formal curricula. He also works to enhance student engagement with the platform with the intention of aiming to maximize its educational impact, as I'm sure you, the audience, have probably come across the content available at osmosis.org. So today we're very privileged again to have Dr. Azzam share his expertise on enhancing emotional resilience and prioritizing well-being for both personal and professional success. Please join us in welcoming Dr. Azzam. Hi team, nice to sort of virtually hear and see where you're all coming from. It's nice to see the global reach for this webinar today. Yeah, it's awesome. We have people from all over?from South Africa, Saudi Arabia, all over the US, Turkey, Germany, and everywhere. That's awesome. And like we said, this is an interactive chat. Any questions you have that come along, please drop them in the chat, and I guess we'll get started. So, throughout my education, you know, this being the topic of resiliency and wellness, I've seen different attitudes emerge regarding resiliency and wellness. But for someone who's been like you throughout his career, being involved in education for such a long time, you've seen it evolve a lot more. But I think it's important we start off with definitions?you know what we're talking about?so let's start off with resiliency. Can you define what that is to us and what the term means and encompasses? Sure, thanks so much for the definition start. It's true that a lot of stuff in mental health can feel soft and squishy and less sort of measurable or less sort of precise than the rest of medicine or rest of healthcare. I think an easy definition of emotional resilience is basically the ability to bounce back from negative experiences. So we're all going to have positive and challenging experiences in life that are emotionally triggering, and so emotional resilience is the ability to cope with that, handle, process those emotions, and be able to not have them take over or overwhelm you in whatever experiences you have in daily life. So somebody who has high emotional resilience is able to handle negative experiences that trigger negative emotions much more adaptably than someone who has low emotional resilience. Yeah, so that's a good framework to encompass what resiliency is?being able to bounce back from all the things that we go through as students, as residents, and as physicians and everything else in between. Throughout med school, students always face stressful topics and things like that. Can you maybe share a story about a topic that you've had and how you've navigated and encompass resilience? Sure. I'm a big fan of transparency in health professions education. I might intersperse medical and health professions education here throughout this just because medical education is narrowly medical students, future physicians, and of course health professions education is more broad?we're including our nursing colleagues, our physical therapy student colleagues, etc., etc. So forgive me if I narrowly just say medical, but I'm really referring to all health professional students. Training is hard. Training is hard for everyone, but becoming a health professional has historically been particularly grueling and gruesome. We've all heard horror stories, including some people who actually take their lives through the challenges of health professions training. So I think being transparent as educators allows students to see a path forward and to see that they are not alone in their challenges and with tackling the long, challenging journey that doesn't have to be as challenging as it is right now. I'll disclose that during my intern year of my psychiatry residency, I experienced a major depressive episode. It was a really challenging year for me. I was far away from family and loved ones. I had some interpersonal challenges with a breakup with a serious girlfriend at the time that was really painful and wounding. Experiencing that major depressive episode during one of the most challenging years of medical training was overwhelming for me, and I needed to seek help to ensure that I could continue to get better and be as well as possible for my own patient population that I was privileged to serve. I think the key message here is you are not alone, and it's actually okay. I like to say it's a sign of strength, not weakness, to ask for help. So I'll start there. More than anything else, I hope very much that your generation, future generations of health professional students, see the value of emotional wellness as not optional but rather essential to being the best health professionals you want to be. Wow, thank you for sharing that. I think that's a very personal and very sensitive topic that you just shared. Thank you for sharing it, especially amongst a moment where, till this day, stigma towards mental health is still quite a topic that not many feel comfortable to talk about nor to acknowledge even. A book that I've been reading, The Road Less Taken, is actually talking a lot about, like you have said, the part where in order to bounce back from those moments where sometimes it feels like we're at rock bottom and there may be no other way to proceed. I wanted to ask for your opinion or experience towards this stigma towards mental health. Has it changed or...? Great topic. Totally love that. Love the question. I've been through it. Thrilled that certainly in the United States, I've seen a large reduction in stigma towards mental health and well-being. Even the term mental well-being used to be sort of shunned upon. Over my 30-year career, I've definitely seen much greater call for transparency but also just like mental health is equivalent and should be treated equivalently to physical health. Just like we would declare and want to declare in an ideal world that health is a human right, I would offer that emotional health is also a human right. Now, we have a long, long ways to go to that fantasy future world where there is no stigma against mental health, mental illness, emotional challenges. But I've definitely been heartened to see how much more openness and willingness there is to see emotional health as an important part of human health. I'd be curious from both your countries that you're training in and your own lived experiences whether you're seeing reduction in stigma or whether it's still just as stigmatized as it was years ago when you were earlier in your careers and younger. Oh, that's an interesting question. I need to think about mine a little bit, but yes, here, if you know right away, I mean, just like I started this talk, through my education, I've seen a very transformative change, especially I think there was a big changing point, especially from what I'm seeing in residency programs, all of them starting their wellness programs around that time and trying to sell that as a way for residents to choose that hospital, for example. But, you know, growing up, I'm from a Middle Eastern family. Mental health and wellness is sometimes not as an approachable topic in some of these households. But then being in education where I did my undergrad here at UFT and then went to Grenada from medical school and rotations in New York, experiencing all these different environments, I can kind of see how mental health is actually viewed in different communities. There is still very much difference in each of these countries that I've been through. Some are more open than others, and I think are on the path closer to that world where you envision where it's not as stigmatized. Hopefully, we can all get there eventually. But yeah, some areas of my education sometimes are very open to discussing and urging that speak; other times it's kind of brushed away, and you have to bottle it up and deal with it as everyone else has. It's definitely something that I'm seeing change, hopefully, more towards that open direction where we can all be transparent about all the challenges we're facing. So that's my experience, but I still think there's a long way to go, like you were saying. Parsa, while you're still thinking of your answer, I'll just offer another anecdote and then see if you have thoughts too. I also come from a part of the world?I'm half Palestinian, half Armenian?and certainly there's a lot of stigma historically in that part of the world against mental illness or emotional resilience and well-being. Even my own parents, as immigrants to the United States, when I chose to do psychiatry, they didn't say this exact sentence, but it was almost this sentence: "Wait a minute, you went to med school, and now you're going to waste four years of med school by going into psychiatry? Like, what are you doing? That's not medicine or that's not what we thought you were going to become." I'm happy to say that over time, I'm blessed with parents who want what's best for me; they see that I'm happy being a psychiatrist, and then they come around. But you know, that stigma exists in my own family as well, even in my own career choice. So I agree there are certain parts of the world where this is more challenging. Certainly in medicine, in order to make it into medical school and be a physician, you have to get down and do the business, and there's no time for soft, squishy, emotional stuff. I appreciate that. We again have a long ways to go. Parsa, I don't know what your experience has been with stigmatization of mental illness and mental wellness. It's definitely, for a bit of disclosure, I moved from Dubai to Turkey, so there was a bit of a cultural shift for me in the sense that I used to be in an international community, and now I was in a more, I would say niche, but I was more surrounded by the local community, which was nice. But it was also a very interesting moment for me to discover sort of the priorities that are given in different cultures. What I mean by that is how, being in an international community, probably a bit similar to the States, it was a bit more common over there to talk about mental health. In Turkey, it definitely is among, within, I've noticed, like either just a bit older than me or a bit younger than me, those born in 2000, 1995, or born in 2008, like it's quite a prioritized topic and given a lot of attention. However, as we see toward the older population, I might say this might not necessarily be the case for everybody, where for some it almost seems like it's a card being used. At least that's one anecdote that I'm using?the mental health card is just to run away from work, which I don't know why they presume work is the definitive treatment toward mental health struggles. One might be pacing, but there's definitely a lot of room for improvement, I would say, at least for or within the Middle East. I've seen it being a common topic or in the sense that it's more not readily acceptable throughout the whole population. Not many are even aware of it that it exists, especially how it could definitely lead to physical signs. It's not just, as some might presume, sadness or just in your head, so to speak, quote-unquote, or "You're just a teenager, it's just hormones, it'll pass," whatever. It's unfortunate to see those who really had to depend on their similarly aged friends who would understand them better than their own family or sometimes even among care workers. But yeah, I'd say there's a lot of room for improvement. Well, hopefully the panel, I mean, the folks who are listening today will hear that all those on this panel are strongly endorsing moving away from stigma and toward acceptance and resilience strength. Yeah, especially that topic of bringing in the elder folks. I think it's definitely a generational thing as well, where especially younger students we can see how mental health is affecting us directly, and especially with all the compounding effects of our society and the developments. There's a lot of compounding factors that have made it a stronger burden on us of this mental health and me giving rise to the importance of the resilience of and wellness. So now, what are some of the strategies that you know people from these groups who are experiencing mental health?what are some support things that you can suggest for them? Sure. We can think a little bit about strategies for emotional wellness and resilience. I'll just sort of rattle off a couple. This isn't in a logical organized framework kind of thing, but I know I did look up in prep for this a sort of emotional wellness toolkit that I hope Steph will post in the chat. I went to the National Institutes of Health for a wellness toolkit and found a PDF of six strategies for improving emotional health. I'm just going to rattle them off, and then we can think about if any of these are ones that we want to explore further. The first one is to build resilience. The notion here is that you don't need to feel you're doing it alone, and sort of building resilience involves dealing with healthy ways to cope with the challenges and stresses you face. That can involve strategies that you use as an individual human to feel healthier, for example, listening to music if that helps you cope, building a strong support network?loved ones, friends, family, those kinds of things. The second one is around reducing stress. Easier said than done when you're experiencing the stress of health professional school, of course. Planning, advanced planning, designing extra support when you're nearing exams would be an example of reducing stress. You can't eliminate the exam, but you can try to distribute the prep for it upstream so that way it reduces the stress of the exam the night before or the day of. The third one is getting quality sleep. This is kind of intuitively obvious and goes without saying, but the reason we need hours of sleep is physiological: we need sleep to recover. Pretending we don't need sleep is naive and a recipe for trouble. So acknowledging that sleep is part of human health and well-being, making sure you do as much as possible to get regular hours of sleep, regular pattern, minimizing disruptions every night. When I go to bed, I'm turning off all my notifications, even though all of us sleep with phones near our beds, presumably. Turning off notifications so there's no chance that's going to interfere, optimizing the environment that we're in to ensure a good quality full night's sleep, defined as six to eight hours depending upon your body and physiological needs. Number four is to strengthen social connections. I like to point out we are mammals, and by definition, mammals like being around other mammals. So we're leaning into our physiology when we say it's actually good for me to be with other people, certainly. A big challenge during the worst of the pandemic: we mislabeled it social distancing, but we really should have labeled it physical distancing because we could still be socially connected. We needed those social connections, as we found on Zoom and remote, six feet apart in the US and however many meters in other countries. What we needed was that social connection to maximize resilience throughout that worst of the pandemic. I'm still harping on the mislabeling, but I think we could have done a better job with strengthening social connections during the pandemic. Number five is to cope with loss. Loss is a part of human life. We have a full range of human emotions, and if we try to suppress the so-called negative half of human emotions, then we're living through half of human emotion, and we don't want to do that. We want to have the full range. Obviously, how we express that emotion and how we experience them is important. The key number five is coping with loss. Sadness is real. Living and experiencing that sadness in healthy ways is the optimal strategy. Learning how to cope with loss and going through grieving or loss in as healthy a way as possible is the key step. Number six is mindfulness. The concept of mindfulness has really become much more popular and prevalent now than it once was. I define it colloquially as being fully present. It's super easy to be distracted. I could pull up my phone and look at a text; I even got a ping during this, and I was like, "Oh shoot, I forgot to turn off my notifications for this talk." Being fully present with both of you now is an example of mindfulness, being aware of everything on and around you. I keep noticing that lamp behind me is sort of in the way, so I'm trying to sit in front of it. That's me being mindful of the external environment and how it's playing out with my ability to be fully present with you all today. So, I'll just rattle off those six strategies one more time, and I think Steph will post it in the chat: build resilience, reduce stress, get quality sleep, strengthen social connections, cope with loss, and be mindful. Those are the six right there. Yeah, those are amazing. Just each one of those we can talk about for a long time. Those are especially important for anyone going through even the good times, the bad times, anything in between. It's just being able to recognize that we are social. I love that?like, we are at the end of the day humans, mammals, just like penguins, just like any other animal that loves to do that social interaction. That was missing for a lot of people during COVID, and just how you were saying about changing the term from social distancing to physical distancing so we can keep that social aspect?that's so strong. I haven't heard of that before, and it's just something that I think could have been rebranded because a lot of students?my younger brother who had to stay at home for a lot of his school, a lot of those social connections that I developed, he missed out on during his high school and first year of undergrad. It was just a big difference in how I experienced those experiences and how he experienced them. For students even younger, that's a lot of change in that support. Yeah, the pandemic was awful for all of humanity, worse for some than others, of course, and no one chooses what age they are when a pandemic comes. There was certainly a different distribution of population that were disproportionately affected by the pandemic. The subsequent pandemic that the world is continuing to climb out of is the emotional pandemic and the psychological trauma that we all experience from that. Definitely things like being transparent, posting talks like this, and just being out and talking, and all the teachers like the lovely ones we have in our chat who are paying attention to students and bringing those concepts up to the forefront and discussing them being open and transparent?this is the change that I think will help us push towards that utopia-like society that we can hopefully one day achieve, and that's definitely things we should be aiming for. Yeah, I really do wonder in an ideal world what sort of actions institutions could be taking. I'll give a context before I move on. I remember, for example, in school, there was once given out a screening survey to see who was, I assume, depressed. There were very interesting questions; some of them I still recall. For example: would you change yourself if you could? Do you feel happy with life? Then there was a Likert scale where you rate from one to, I believe, seven, and you write your initials, so it's anonymous but your initials are there. They tried to follow up with some students. What it turned out was that those students they followed up with, it was more of a "you don't have what I think you have, the depression," right? Like, you're just sad at the moment. Usually, a lot of them were lost to follow-up?I like to say lost to follow-up because I really do think especially at the age of teenage years or even at the age of 18, somewhere still in school, it's that expectation of them to know how to process their emotions is maybe too much to ask for, especially when they're in a system where their mind is occupied by school. Many are fine with being there; some absolutely do not want to be there. But action was not taken as much as it should have been. With that being said, I was wondering what sort of adaptations you would believe could be implemented at institutional level, whether maybe for school or for medical school, if you'd like to comment. Yeah, we'll start with the school level thing. Thank you very much for the question. I'll talk about what we do here at UCSF in the School of Medicine as one example, and then we can broaden it to think about other institutions that might want to do things. Most universities hopefully have some student health services available to university students, and oftentimes that may be the kinds of things that are more common in young people: coughs, colds, upper respiratory infections, other maybe sexually transmitted diseases, other kinds of diseases that occur in relatively healthy and relatively young individuals. Many institutions will realize that emotional wellness and well-being, the risk for some of the mental health conditions emerge in university settings as well?the stress of being in school, you may experience some major depressive episode or anxiety symptoms, for example. Ideally, universities are going to have both physical and emotional health services available at student health. Certainly, we have those here at UCSF. In addition to that, because the experience of medical school is known to be extremely challenging, we have a separate med student well-being program in addition to the baseline student health services that are available for all UCSF students. The med student well-being program includes a psychiatrist and a psychologist on staff who are firewalled away from academic services. We have a big wall between students who are seeking emotional health and are being seen by mental health professionals in the university clinic, provided for that big firewall from the academic advising services, the faculty that are grading the students, that sort of stuff. We should have that firewall because students are seeking care and want to know that their emotional health services are confidential per their wishes. That's why it's a firewall, but it's there for the students, and they're available. That's made available for the students as part of their enrollment at UCSF School of Medicine. The same thing applies at other institutions, other health professional universities. Knowing that our students are under a lot of distress and stress during professional training, wanting to invite universities to provide those additional services. Another concrete example would be some of the wellness apps that are available. Headspace and Calm come to mind as two that have achieved quite a bit of penetration in the app space. A university can decide to invest in that for their students, so rather than the students having to pay a subscription for it, maybe the university says, as part of your tuition dollars, we're going to make sure this is available to you. I'm starting to see some universities beginning to see the value in investing in those services to help their students asynchronously when those clinics or med student well-being clinics are closed or when the psychiatrist or psychologist is not on call, for example. Just the health aspect of having mental health therapy available to students and the importance of that firewall is very important. Even in my school, for example, when I was in Grenada School, there was still a stigma that we had as students that even though they told us there would be a firewall, the one you described, where the students and what they discuss with the therapist and the psychiatry and psychology services there would not be shared with the dean, there was still a big stigma for students to go and seek out there, and sometimes we had to push each other to go and seek those services. That's one thing I've noticed: despite the services being there, it's hard sometimes for students to go and seek them. What are some things that you think cause that? I'd like to think about this as a positive peer pressure thing. Peer pressure is real; I'm not going to deny that. What I want to do is encourage peers to push towards health rather than unhealthy or mental well-being. Offering a hand of support, inviting your peers to be aware of those resources if you're worried about them?that's motivating towards health rather than something like, "Let's go out drinking to celebrate finishing the test." Nothing wrong with celebrating, don't get me wrong. But instead of a competitive culture, we can create a collaborative culture in medical school. Anecdotally, when I was in med school, we used to half-heartedly joke: what do you call the person who graduates last in medical school? In the academic hierarchy, you call them doctor because if they finish the minimum requirements to complete medical school, the school deems them adequately prepared to go on for the next level of training. So you don't want to be fighting for the top score; you want all of us collectively to do as well as we can. A rising tide raises all boats. A collaborative rather than a competitive mindset. Positive peer pressure: let's use social media to promote mental health and well-being. Let's use those tools. Universities can do this too?remind students about the services that are available rather than keeping it in the shadows. I appreciate the firewall of clinical services, but that doesn't mean you can't be out and proud about the services we offer to students so they can seek help proactively. I don't know if I'm answering your question, but that's where I would go. No, that's right. It's just the importance of the peers and making sure that services are known. That's something schools can be doing. The idea of the social environment pushing each other and raising the whole collective as the student body toward a better outcome?that's amazing to hear. I would offer that a lot of times students are in individual universities, so you're only thinking about that one community that you're a part of. My cohort of second-year medical students at Johns Hopkins, but you are part of a larger community of second med students in the US, second med students in the world. We can think about other communities of support beyond your local institution. That's what the OIE program is after all?a network of health professional students globally. Similarly, there might be a network of students interested in surgery, and you might find a surgery interest group beyond your university. Then, talking there, looking into how you all support your emotional well-being. It sounds crazy for me to say, but I don't think it's crazy at all. If there is some mechanism for that community to talk about emotional wellness, you're going to find that initiating those discussions will lead to greater emotional wellness and resilience because you're talking about it rather than pretending it doesn't exist or that everybody's doing just fine. Just a quick interruption: we have a couple of questions in the chat host and panelist section. I was going to bring up one of these questions because the discussion about peers and students, one question we had in the chat was: what if someone doesn't think they fit in well with other students? One of the questions was a student feels they don't get along with peers. They think everything is too competitive, trying to make themselves like gunners, and they don't fit in. They feel they fit in, is what I'm getting from that question. They think their reasoning behind things and the way things are taught, their critical thinking is often labeled as unnecessary. They're wondering how to navigate that situation where it's difficult to work with peers in that scenario. First of all, thank you for writing that, and I'm sorry you're experiencing a cutthroat competitive climate at your university. The first thing that comes to mind is seek help. I'm glad you asked the question here. I don't know all the context and details, so I can't answer with great certainty, but I'm pretty sure there are academic support services at your university. At the very least, you could approach academic support services. You may not be in academic difficulty; you may not be at risk of doing poorly on exams, but academic support services are there to help and even just to talk to them about how you feel disconnected from your classmates, that they're cutthroat competitive or gunners, and you don't feel that way. Having that discussion with that human is going to make you feel a little better because you're letting out those emotions and that sense of disconnect. In an ideal world, that person will know of other applicants, other current students, or other resources you may not know about that exist at your school to address that sense of competitiveness that you're not a part of or that sense of loneliness or disconnect. Some students are lucky enough to be at universities where there are nursing students and physical therapy students, so connecting with some of the physical therapy students on campus so you don't have that same cutthroat competitiveness within the same program would be a wonderful antidote to the toxic environment you may be experiencing. Joining student clubs or organizations where it's not competitive but really collaborative might be an example. Anecdotally, I sang acapella in medical school, and that was fantastic because it was a great chance to do something that wasn't schoolwork. It allowed me to interact with other people from other programs, and it was tremendously therapeutic for maintaining balance in life during medical school. I hope whoever had that question, if they have a follow-up question, be sure to ask it. Anyone else who has questions or experiences to share, please share them, and we'll help bring them here with Dr. Azzam. One thing I'll say is I want to differentiate between the range of normal emotion and what we in psychiatry would think of as clinical diagnosis, like a major depressive episode. When I talk to my patients about it, I like to use a framework: capital letter D depression versus lowercase d depression. Lowercase d depression is how we talk about it socially?"I feel depressed because my dog is sick," or "I'm worried about politics," or "I feel sad because I miss my family while I'm in grad school." That's the range of normal. Capital D depression is more severe, as defined in psychiatry as a major depressive episode: sad more days than not, continuous for at least two weeks straight, with five of nine diagnostic criteria necessary to meet that. Capital D depression is serious and needs support beyond the routine support everyone has available: mental health professionals, sometimes medication, sometimes talk therapy. Capital D depression versus lowercase d depression: many people experience a lot of lowercase d. In my own patient population, I ask them if we're talking capital D or lowercase d depression and learn from them to differentiate. Same thing with anxiety symptoms: range of normal versus clinical beyond range of normal, which we call capital A. I want to make sure I clarify that framework for everybody. Thank you very much for the clarification. That's definitely something very important to take into account, especially because sometimes one could be in the capital D as we speak but have no idea until pointed out by others. Usually, people who tend not to express themselves, keep it bottled in, and as we know, keeping stuff to yourself as social beings and not addressing root causes will eventually probably lead to unfortunate complications down the road, even though it could have started from the smaller d initially. With that being said, I'm glad you brought up aspects of treatment because there's a question from one of our attendees: there are many clinical cases involving patients dealing with generalized anxiety disorder, obsessive-compulsive disorder, often triggered by factors like the pandemic, digital overexposure, or deportation-related issues in the US. While these patients are receiving pharmacological and psychotherapeutic treatments, are there other additional strategies or tools that could be recommended to support their well-being? Thanks, that's a big question. I'll start here and get more specific. In the US, there's a six core competencies that all physicians should be competent in to practice medicine. One is direct patient care, second is interpersonal communication skills, third is professionalism, fourth is medical knowledge, fifth is systems-based practice, and sixth is practice-based learning and improvement. Systems-based practice is where we acknowledge that no clinic or physician works in an island; they are part of a system. Being competent in systems-based practice means knowing the resources and tools available at a system level to optimize patient health. For example, my wife works with a patient population; she's a pediatrician with a public health background specializing in childhood obesity. She works with patients concerned about risk for deportation given the US climate. Within the system, administrative leaders provide guidance to clinicians on what to do if immigration officers appear in clinics. Similarly, within the University of California system, I receive notifications on what to do if federal research funds are frozen and who to contact. The question was about individual patients experiencing clinically significant OCD and seeking both psychopharmacologic and behavioral health treatment, and what to do when external forces exacerbate symptoms. The answer is to think about systems resources in addition to individual clinical services. Patients can ask providers about system resources beyond what individual providers can do. Collectively, clinicians are expected to know system resources available. I hope I answered that question but want to acknowledge the distressing and stressful situation in the US with the current administration. There is a lot of work to mitigate uncertainty, and resources are available. As I rotated through hospitals, what makes a good doctor is when they have resources available, are knowledgeable about them, and share them with patients and students. That elevates the level of care; patients appreciate doctors who provide those resources. Going forward, knowing what's available is definitely something you can recommend. Now, with patients going back to students, we had a question about students feeling marginalized, coming from different countries, feeling conflicts and emotional problems among interns and residents, and perhaps bullying. How would you deal with that as a system or administrator? How do you reduce that and create a better environment? Sorry again you're experiencing that. This is far from the ideal world, the fantasy where we have high-quality, professional teams that respect and honor differences and can rise above such behavior. Anyone in an organized training program has a training director or leader responsible for educational climate to ensure it's as healthy as possible. Each accrediting body mandates minimum requirements to ensure a healthy environment. One minimum in the US is students have mechanisms to report abuse or mistreatment they've experienced. These are mandated by external accrediting agencies. Med schools provide reporting mechanisms, usually anonymous to protect privacy. I encourage students experiencing bullying to feel empowered to find out how to report mistreatment. People worry about consequences if they report; anonymity may not eliminate bullying but is an empowering mechanism to declare inappropriate behavior. If comfortable, approaching program leadership non-anonymously creates a paper trail where leadership should address the situation. I don't know the local context, but ideally, people in education are committed to program quality and trainee emotional wellness. Everything I said about school level applies to residency and graduate medical education levels. There are mandatory mechanisms for trainees to declare mistreatment. I'd like to comment for Istanbul or Turkey that the same applies. Probably applies elsewhere too. Seek help from your local medical association; there are resources and opportunities for personalized help, especially for systematic hardships like bullying. Staying quiet is not something you should do in this case. There is hope and a way for change. As Dr. said, we're far from the ideal world but hopefully will see change over time, especially with great work and contributions toward destigmatizing mental well-being in health care and other fields. As we approach the end of our podcast time, what personal advice would you have for maintaining well-being? I can start. I always recommend checking in with yourself. One of the best ways to do that is journaling. You probably heard this from every other website or health podcast, but it helped me check in with myself and see how I'm feeling. Sometimes we forget to process a lot of emotions, especially in busy healthcare environments. With that, I'll pass it on to Dr. Azzam. Thanks for that question. I'll share anecdotal stuff from my life and some advice I heard as a student. Figure out what things give you disproportionate joy. Everyone's busy, so you can't create or invent time, but you can think about how you use your time. For me, I sang acapella in med school, which I really loved, and I also played intramural soccer. Those two things gave me disproportionate joy, so I prioritized them. There were things I had to give up because I didn't have time, but I knew what was most valuable to me. For you, Parsa, it's journaling. That may not be the case for everyone else. I invite introspection to think about what gives you the most joy you refuse to give up during challenging training years. That may evolve over time, but thinking about it helps prioritize your time. When I was a med student, I was involved in the American Medical Student Association. I attended a national conference where Abraham Verghese, a renowned US physician, was keynote. He gave a talk on life-work balance and used a metaphor I've used for 30 years. He asked to think of your professional identity as a train on a track moving forward: undergrad, grad school, med school, internship, residency, fellowship?ideally moving forward continuously. Your personal life is a train on a parallel track: dating, marriage, family, moving forward sometimes faster, sometimes slower. The secret to success is not which train is ahead but making sure neither falls too far behind. If professional life is lagging, prioritize it; if personal life is lagging, prioritize that. Life is busy happening while you're busy being a health professional student. We need you emotionally well and healthy for your career. There's no better time than now to start prioritizing balance. I love that analogy. This movement toward better mental health across all disciplines is important. In that goal for the future, things like terminology changes?for example, social distancing to physical distancing?are helpful. One question we had is about terms like burnout. How do they influence how we discuss mental health? The person said burnout blames the individual for working too much, sometimes their fault, instead of being an institutional issue. I agree; we have work to do. I hope this was part of the work toward a healthier future for all health professional students. During my residency interviews, every program had some sort of wellness program: extra days off, soccer teams, sponsoring lunches to interact outside medicine. That's encouraging. Going forward, what are your hopes for healthcare culture, emotional resilience, and wellness in the next decade? Let's move toward that fantasy future. In an ideal world, that future comes in 10 years. We have a long way to go, but I'd love a place where health professional students feel welcome as who they are, fully supported to advance our mutual goal of being healthy humans providing high-quality care. Feeling safe during the educational program is one of the best things I've experienced. Some professors and doctors who shadowed me showed genuine interest in wanting the best of me and ensured I got the most despite their busy schedules. That passion I felt from the start as I entered. I believe in that future. If we are the future generation shaping the next generations, rather than pulling up the ladder, we can lower it for future generations and make it easier for them by having these discussions. Last question: how can depression in medical students in countries like Colombia with suicide be addressed if we do not speak out or express it? I think it all comes through changing the culture and shifting toward that utopia where we can discuss and have transparent talks. That's the future I'm looking toward, and I'm sure you all share that. As we wrap up, if anyone else has questions, remember: seeking help is not a sign of weakness, it's a sign of strength. Self-care is not selfish, it's selfless. I love that. I wish I could get more of these reminders daily. I'm going to start remembering everything you said, Dr. Towards systematic change, I like to end with this: change starts with you. What we can take away from this meeting is, especially regarding stigma, let's start talking about it. It's a serious issue. Hopefully, we can all do better toward the future. Thank you all for joining, tuning in, and for the questions and lovely interactions from around the globe. Thank you again to Dr. Azzam for joining me and Parsa in this lovely episode. Don't forget to check osmosis.org for events and webinars. I'm sure you'll look forward to many upcoming webinars that I'll be hosting, including one next week. Apart from that, thank you very much for joining, and see you in our next episode helping current and future clinicians focus, learn, retain, and thrive. Learn more.