An Interview With Psychiatry Residency Program Director Toni L. Johnson, M.D.

Dr. Johnson is Vice Chair and Residency Program Director for the psychiatry residency program at East Carolina University, Brody School of Medicine/Vidant Medical Center in Greenville, N.C. Previously, she was the program director at Case Western Reserve/MetroHealth System in Cleveland. She completed residency in psychiatry at the Cleveland Clinic, where she also served as chief resident. Dr. Johnson has interests in graduate medical education and meeting the mental health care needs in underserved and minority communities.

Oliver M. Glass, M.D., is Editor-in-Chief of the American Journal of Psychiatry Residents' Journal. He completed his psychiatry residency training at East Carolina University and is a PGY-VI forensic psychiatry fellow at Emory University in Atlanta.

Dr. Glass: Dr. Johnson, I appreciate you agreeing to participate in this interview. Could you please tell me what drew you to serving as a psychiatrist in eastern North Carolina?

Dr. Johnson: Thank you for this opportunity to share my experience, Dr. Glass. Many years ago, I made a commitment to practice and teach in the most underserved communities. It is in these settings that I gain the most fulfillment. After I completed psychiatry residency training at the Cleveland Clinic in Cleveland … I spent a few years in Cincinnati. Then I returned to Cleveland where I practiced for 12 years in the MetroHealth System, a teaching affiliate hospital for Case Western Reserve University, before relocating to eastern North Carolina. My outpatient practice in Cleveland was an inner-city colocated neighborhood clinic in the heart of the city. I was the first psychiatrist in that clinic to bring a resident, and eventually we set up a resident clinic. After 12 years there, I decided to look for an academic setting again primarily serving an underserved community, but this time I wanted a warmer climate! So, I visited Brody School of Medicine at East Carolina University and its partner, Vidant Medical Center, in Greenville, North Carolina, and immediately felt a connection with the missions of these institutions. Both institutions have a legacy of commitment and service to the surrounding communities. They each purpose themselves to improve the health status of citizens in rural eastern North Carolina, and the Brody mission includes the goal to enhance the access of minority and disadvantaged students to a medical education. This is the perfect learning environment to serve those most in need while also educating and training students and residents to do likewise.

Dr. Glass: What are the most desirable attributes that you look for in an applicant when he or she applies to your program?

Dr. Johnson: That is an excellent question. If only program directors had the perfect recipe, right? I have been a program director for 11 years, and what I know for sure is that there is no perfect recipe of ingredients for the ideal psychiatry resident applicant; however, I believe the best training program is a program of diverse residents, and each resident has strengths. We learn from each other and become better individuals in a program built on diversity. I like to use the analogy of a winning football team (which is a sport I love to watch). A good football team needs the strong, upfront heavy-lifters to be on the line as well as the speedy skill players in the backfield. Everyone comes to the team with certain strengths and talents, yet all players must be athletic and dedicated to the team. Hopefully, they all have a competitive spirit and a love for the game too. For residency, all members of the residency team need more than academic abilities, although that is definitely required. I am looking for resident applicants with maturity, self-awareness, good emotional IQ, a dedication to teamwork, and a fascination with people's behavior, in general, and the human brain, in particular. If a resident applicant has overcome a personal challenge, learns from it, and is a better person in the end, then that interests me. I want an applicant to tell me the story of their journey to become a psychiatrist. All psychiatrists should be able to share a story!

Dr. Glass: Do you have any suggestions for trainees that experience burnout?

Dr. Johnson: Unfortunately, the entire health care system is too often the least healthy work environment. It is ironic and extremely unfortunate that our work and learning environment can have a negative impact on the health and well-being of the physician in training. Thankfully, the need to address this has become the focus of the Accreditation Council for Graduate Medical Education. As of July 2019, the common program requirements for all specialties will require all programs to show evidence of faculty and resident wellness initiatives. This is good news for trainees, since some programs were not as supportive of residents seeking support and treatment as they really should have been. Psychiatric physicians should take the lead, and psychiatry residents should become active participants in these initiatives, which can positively impact their training experience. Another important understanding is that how you practice and address personal needs in residency is often how you will continue after residency. So, we must model wellness during residency to promote wellness after residency. When we create and support wellness in the training experience, we build a healthier work environment for all practicing physicians.

Dr. Glass: How can a trainee get help if he or she has an untreated mental health condition or substance abuse disorder?

Dr. Johnson: Ideally, a resident should speak with their program director or graduate medical education (GME) representative, who can refer them for professional help. As mental health professionals, it is very important that we not attempt to diagnose or treat a trainee in our program. That is a boundary violation. Our role as clinical educators is to connect medical students and residents in need to professionals outside of the clinical learning environment or at least with someone who will not be supervising the trainee.

Dr. Glass: How should programs help the psychiatry resident who trails behind in one or more of the milestones?

Dr. Johnson: It is the responsibility of the faculty in the program and specifically the program director to systematically inform residents of their progress along the milestones for psychiatry competency. This should be an ongoing process [that] happens at many levels and in many ways, both verbally and in written format, as well as formally and informally. Residents can only improve if they know specifically what they need to improve upon and in what way they can accomplish this. When we see a struggling trainee, we first try to identify what is the specific knowledge, skill, or attitude that needs improvement. The more difficult part often is why the challenge exists. For example, a resident may be challenged by not being able to report information accurately during handover (sign-out) to the team. Is there an attention problem impairing the ability to receive and prepare the data? Is there an organizational challenge in structuring the data? Is there a communication difficulty in verbally reporting the data or an EHR [electronic health record] challenge in storing the data? We like to catch these challenges very early on and develop a plan for improvement with specific and measurable steps for the resident. I really am a fan of quality improvement, so I may develop an improvement plan for the resident with a PDSA (plan, do, study, and act) approach. We may have a senior or chief resident work with the resident to assist in getting the details of the challenge, and then the resident is involved in creating their plan for improvement. Then we measure and repeat. Thankfully, we have excellent resources on campus, including academic assessment and support to help address the various challenges listed.

Dr. Glass: East Carolina University is known to serve marginalized, underserved patient populations. Rotations span to very rural parts of North Carolina. How is treating those patients different than in urban settings?

Dr. Johnson: As mentioned previously, I have worked in impoverished communities in urban settings and have seen the similar challenges that poverty poses regardless of location. Ability to access quality care and managing life in poverty have some similarities in urban, small town, and rural communities. The mission of Brody School of Medicine and our partner, Vidant Health, is to improve the health and well-being of the 1.4 million people of eastern North Carolina. Like many, this is what attracted me to eastern North Carolina. We have the goal to become the national delivery and educational model for rural health and wellness. The challenge is these folks are geographically spread over a very large rural area with very limited resources. In addition, many of these agricultural-based communities have dealt with deep poverty for multiple generations. On the other hand, the people of eastern North Carolina, however, have an amazingly resilient spirit and strong sense of community, which bonds us together. We saw this recently after Hurricane Florence as well as following Hurricane Matthew in 2016. They way folks with very little to begin with reached out and cared for each other was inspiring. Eastern North Carolina is a unique place.

Dr. Glass: I remember when you had our residency class play a modified version of Monopoly. Can you explain to our readers the reason why you include this in residency training?

Dr. Johnson: I am glad to know you still remember that experience! We know from data gathered by the Association of American Medical Colleges that the parental median income and level of education of U.S. medical matriculates is overwhelmingly from the upper echelon. In contrast, patients who often present to academic teaching facilities are often from lower socioeconomic backgrounds. This is a setup for a lot of misunderstandings and assumptions on both sides. Sociologists have used games or simulations to introduce social stratification and to promote critical thinking. I use a simulated Monopoly game to help learners reflect upon misunderstood attitudes and behaviors of those on opposite sides of the socioeconomic continuum. The boardgame Monopoly is modified and used to increase understanding of the concepts of poverty and privilege in order to challenge learners to consider how socioeconomic resources can [affect] health and health care behaviors. If you recall, each player starts the game with a different income and set of challenges or privileges. Then after we play, we have a group discussion, and each participant has a written self-reflection exercise to complete. I have been able to take this activity to different levels of learners [and] different specialties and disciplines as well as present it on a national level to clinical educators.

Dr. Glass: Immigrants to the United States may have specific stressors that can complicate their access to mental health treatment. Do you have any suggestions for improving access to care in this population group?

Dr. Johnson: Immigrants, like other marginalized groups, are often left unable to access general health care and definitely challenged to access mental health care. This is especially true for undocumented, uninsured, or underemployed immigrants. Many immigrants face the same issues as other patients struggling in poverty, but the situation can be complicated due to cultural, language, stigma, and legal barriers. This really is a larger health care system issue, but the suggestion I do offer is to have academic and community training sites to partner with immigrant communities' social and faith-based supporting structures in order to better meet the health care, including mental health care, needs of immigrants. We also need to increase language capacity of our mental health work force and take advantage of technology, such as telepsychiatry. I believe the health care setting should be one of the many places of refuge and safety for our immigrant communities.