The Dissection of House Bill 867

Author: Julie Parker

‘Teaser web: The ‘Show-Me Compassionate Medical Education Act’ addresses rising concern over med students’ mental wellness.

It looked like a shoo-in. And then it didn’t. By the time House Bill 867 had churned through the legislative process and was awaiting a final look acknowledging the acceptance of conference committee reports, a Senate filibuster over the Right-to-Work vote killed it, along with a couple of dozen bills, including an important public health bill concerning mandatory infectious disease reports.

Authored by Rep. Keith Frederick, DO, (R-Jefferson City) as the “Show-Me Compassionate Medical Education Act,” HB 867 as originally drafted would have established an anonymous online survey to screen medical students for depression and provided for access to immediate help through an existing 24-hour hotline for students in crisis. It would have also required the medical schools to conduct the screening and make the results public after three years.

In its final form, HB 867 dropped the requirement that medical schools undertake this study, but it protected medical students and medical student organizations from interference or retribution from the medical schools when planning or conducting screening for depression or other mental health issues among medical students.

Legislation would have impacted the state’s six medical schools, including four private ones, with a goal of measuring students’ mental well-being as part of a performance measure.

“This topic – a dirty little secret of medical education for decades – badly needs the light of day,” said Frederick. “One of the biggest problems is that medical schools say, ‘we’ve got this covered,’ but they don’t.”


Test Model

Stuart Slavin, MD, director of curriculum at Saint Louis University (SLU) School of Medicine, had pioneered testing in May 2008 as perhaps the nation’s first medical school to voluntarily produce program evaluation data of its kind. Slavin had been alarmed at how rapidly the level of depression, anxiety and suicidal ideation advanced as students moved through medical school. For example, by the end of the first year of medical school, 57 percent of students reported moderate-to-high symptoms of anxiety; 27 percent had moderate-to-severe symptoms of depression.

“Medical students do a very good job of masking their anxiety,” said Slavin. “They have all the stressors – a highly competitive environment, escalating student loans, isolation (geographically) from their home base … at a time when students are also making major life choices – yet they’re afraid to seek help because it raises a red flag for career building.”

With academic leadership support and hard data, Slavin fast-tracked curricular changes that have resulted in improved overall student wellness, earning him a national teaching award and establishing a model for other medical schools.

“Academic leaders were understandably concerned about the possibility of test scores going down as a result of curriculum changes, but it didn’t happen,” said Frederick. “In fact, it had the opposite effect and blew the lid off this problem.”

Frederick called Slavin “a courageous leader.”

“His study and changes to the curriculum at SLU med school were truly groundbreaking, though he's very humble about it,” said Frederick.


Moving Pieces

HB 867 was voted unanimously out of the Standing Committee on Health and Mental Health Policy, which Frederick chairs. In years past, the bill would have then moved to the rules committee, but a relatively new procedure moved it to the Select Committee on Social Services, chaired by Rep. Sue Allen (R-Town & Country).

On April 6, Missouri medical school deans submitted a joint letter of opposition to the bill, stating: “Reporting the depression rates at our institutions will not reduce students’ risk of depression, and we fear it actually perpetuates the stigmas associated with diseases of mental health.”

The deans acknowledged: “We believe HB 867 has good intentions. However, components designed to achieve the sponsor’s goals set back the progress each of our institutions has made with programs tailored over the last 10 years to fit our student populations.”

Frederick observed that medical school lobbyists and administration staff heavily lobbied Allen to sit on the bill.

Allen disagreed; others noted a 2- to 3-week stay is fairly typical.

“A lot of work with the bill sponsor was required to get it to something I was going to be behind,” said Allen, who among other tweaks changed “mandate” to wording that provided medical schools wouldn’t interfere with medical organizations “conducting a study of the prevalence of depression and suicide or other mental health issues among medical students.”

Allen also expressed concern about mandating the state’s four private medical schools, in addition to the public medical institutions, even though the infectious diseases bill required mandates to all medical institutions, private and public.

Frederick said that despite the unanimous vote from the Committee on Health and Mental Health and no testimony in opposition to the bill, he realized Allen “wasn’t going to allow the bill to move forward” and changed the language of the bill.

“Those changes empowered the medical students and medical student organizations to conduct the surveys for depression without interference from the medical schools,” explained Frederick, noting that with that change, Allen agreed to its terms. The bill was voted out of committee April 13, and presented to the full House on April 14.


A National Voice

Britani Kessler, MD, immediate past president of the American Medical Student Association (AMSA), testified to the committee in person, traveling from Virginia for the hearing. Kessler shared that “mental wellness” is their most frequently clicked-on website link.

“The culture of the current medical education system is that you can’t show weakness,” said Kessler. “The rigors of medical school make you sometimes think this sustained high level of stress is normal.”

The AMSA Board of Trustees has expressed interest in spearheading the surveys in Missouri, and perhaps launching a national pilot program. Missouri has been the only state, to Kessler’s recollection, to address mental wellness among medical students via legislation.

“The purpose of the AMSA is to help pre-med and medical students learn things they aren’t taught in traditional medical education,” said Kessler. “We’re very feisty about medical education reform and making sure the social determinants of health are included.”

Frederick said the cost of administering the surveys would be nominal, and is optimistic about funding those expenses.


Reality Check

On April 23, Kevin Dietl, a 26-year-old student who was weeks away from earning his medical degree at A.T. Still University of Health Sciences-Kirksville College of Osteopathic Medicine, took his life. His mother, Michele Dietl, told committee members very soon after his death that “it’s crystal clear that had this measure (HB 867) been in place, we would’ve been able to seek the care that Kevin so desperately needed without fear of repercussion.”

Pam Wible, MD, a family physician from Oregon and a national voice for physician suicide prevention, testified to the ripple effects of such tragedies. A year after Kaitlyn Elkins, a third-year medical student at Wake Forest School of Medicine in North Carolina, died by asphyxiation due to helium inhalation, Wible attended the funeral of Kaitlyn’s mother, who chose the same method to end her life.

“Many of us have considered suicide, but we’re so resilient that we smile and head back into the next room to see the next patient,” admitted Wible, pointing out that physicians have very high suicide success rates because of their intrinsic knowledge of medicine.

Committee members also received written testimony from Karen Miday, MD, a psychiatrist from Ohio whose son, Greg Miday, MD, an instructor of medicine for the Washington University School of Medicine (WUSM) and a hospitalist with Barnes-Jewish Hospital, was days from beginning an oncology fellowship when he committed suicide. Miday, 29, died on June 22, 2012. His suicide note included the statement: “This is just the end of the line for my particular train.”

“The first year after Greg died, I don’t think I could string three words together,” said Miday.


Finally, Movement

On April 27, the House passed the bill 150-4, only needing 82 votes. A joint conference committee unanimously voted in favor of it.

Then the bill hit a major roadblock. It was among a stack of bills held hostage by Senate Democrats in an almost week-long stalemate. Sen. Scott Sifton (D-Affton), a candidate for state attorney general, led the filibuster in the Senate in the waning days of session. At press time, Sifton had not returned phone calls to St. Louis Medical News.

“About 20 minutes before adjourning, the Senate took up the Federal Reimbursement Allowance bill that passed,” said Frederick. “If that nugget hadn’t crossed the finish line, the governor might’ve called a special session to address the ransomed bills.”

The irony of the filibuster fallout wasn’t lost on Frederick, noting the dark cloud that hovered over the 2015 legislative session after State Auditor Tom Schweich (R-St. Louis) committed suicide, followed weeks later by the suicide of a top Schweich aide.


Growing Support

Once modified in the Social Services Committee, medical schools unofficially removed their opposition to the bill, which Frederick plans to pre-file this fall.

“Washington University’s primary concern – voiced by all six Missouri medical schools – was a provision that would have required the State of Missouri to publish the rates of depression among MD students at each of the state’s medical schools,” said Lisa Moscoso, MD, PhD, associate dean for students affairs at WUSM. “In its earliest form, House Bill 867 would’ve required the Missouri Department of Mental Health to determine rates of depression using a state-mandated survey tool, though student participation in the survey would’ve been optional. We noted that a voluntary survey instrument would give schools an unreliable view of the scope of any mental health challenges. We also worried that a government-mandated survey and reporting process for what is unquestionably a sensitive matter would undermine the culture of trust each school strives to build with its student body.”

Moscoso pointed out that even though WUSM had concerns with earlier versions of the legislation, “the measure that was before the Senate in the final weeks of the session represented a reasonable approach to raise awareness about medical students' mental health and to encourage Missouri medical schools to collaborate to identify best practices, particularly those efforts that are most effective at de-stigmatizing mental illness and encouraging students to seek support and services to cope with mental health issues.”

ATSU School of Osteopathic Medicine Dean Margaret Wilson, DO, whose staff remains “heartbroken over the loss of Kevin,” and delivered Dietl’s posthumous medical degree to his family, said deans expressed concerns early in the session about “confidentiality and potential to cause stigma to students.” Since then, “the bill has since been modified and meets with my school's support,” she said.

Calling All Deans

HB 867 also called for “Show Me Compassionate Medical Education Awareness Day” in late August – which still may take place – for medical school deans and lawmakers to collaborate on ways to reduce stressors while maintaining high academic standards among the student population. A key talking point: evidence-based research on depression and suicide prevention.

“Depressed medical students often turn into depressed doctors,” said Frederick. “Taking preventive steps early on could make a huge difference for years to come.”


Editor’s Note: This article focusing on Missouri is a prelude to a national series aimed at improving the mental health of medical students, interns, residents and physicians. The series will launch next month with a look at how Stuart Slavin, MD, MEd, associate dean for curriculum at the Saint Louis University (SLU) School of Medicine, implemented practices to help medical students build resistance to stress and maintain happiness. The in-depth series will also highlight programs other medical schools are taking to address the mental health wellness of students.



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