Dr. Amy Vinson, Dr. Terry Buchmiller, and Dr. Matt Hitron - Mental Health in the Perioperative Space: Yes - we can talk about this

OK, we're gonna go ahead and get started. Um, today, we're gonna be talking about, you know what, there is a big echo up here. See if I can mute this. Are they up there? Do you guys know there's a speaker coming at me. Do you know how to mute this? Yeah, so I'm looking at. I just don't want to mute everything. OK. Can y'all hear me? OK, perfect. OK. That's OK. All right, guys, so today we're gonna be talking about mental health in the perioperative space and um it's, it's gonna be an interesting talk. Uh, myself, Terry Buck Miller, and uh um a colleague of mine, Matt Hitron, uh, his internal medicine physician now does uh research in oncology. And what I want this to be is a real beginning of a conversation. We don't have any financial disclosures relevant to the material presented today. However, uh, both myself and Doctor Hitron are trustees of the Massachusetts Medical Benevolent Society, um, and I'm the current treasurer of that. I also, um, represent the National Academy of Medicine to, uh, for, I represent the ASA to the National Academy of Medicine. I'll be speaking about that. I'm still getting a real echo up here, um, and I don't know where it's coming from. If, if it can get fixed, that would be awesome. Thanks. So, our objectives today is to talk about the burden of mental health care, um, and mental illness and the stigma of mental health care in clinicians and in the perioperative space. Um, we're gonna talk about areas where improvements can be made to destigmatize mental health care, talk about various support constructs that are available both at Boston Children's and departmentally and um, The state of Massachusetts and nationally for people who are struggling, um, or for colleagues of yours that are struggling. Um And we're gonna give a real illustration of the toll of various uh forms of mental illness. Um, we're gonna talk about substance use disorder, we're gonna talk about suicidality, we're gonna talk about depression, anxiety. Um, this is not gonna be a talk on burnout for once, uh, as a wellness topic. So, thank you for, for joining in. In terms of introductions, um, Doctor Hitron Matt was raised, uh, born and raised in Massachusetts, went to McGill for undergrad, and then he got his MD at, uh, you know. He did an internal medicine, um, internship and residency at BIDMC and then started a fellowship but didn't finish. Ultimately, he ended up doing research in biotech and has really focused his career on oncology drug development since then. He's on the board of trustees of the Massachusetts Medical Benevolent Society, um, and he lives with his wife, his 18 year old daughter who just got her first choice at college. Um, His son, who's nearly 14, 2 cats and a golden retriever, um, in his free time, enjoys music, piano, and guitar, like myself, I didn't know that about him. Reading, hiking, um, and spending time with friends. Uh, you guys know, Doctor Buck Miller. Uh, Terry was born in Northern California, uh, did undergrad at Pacific Union, and then, um, med school at UC Davis before going to a surgical residency at UCLA and a P surgery fellowship here. She then went back to UCLA and, and found her way back here, uh, focusing on fetal care. She's an associate professor at Harvard Medical School. Um, what you may not know about her is that she played violin in the Longwood Symphony for 20 years, is a very avid runner, um, is involved in a nonprofit board in Vermont, and from a well-being standpoint, um, was a member of the APSA task force, which became the Committee on Wellness and was chair of that from 2022 to 2024, um, ultimately leading a wellness day at their annual meeting this past year. Uh, for myself, I was born in Savannah. I went to Georgia Tech and then the Medical College of Georgia before coming up to New England and staying. Did a pediatric residency at Hasbro, anesthesia residency at Beth Israel and fellowship here and have stayed. Uh, my focus has been on well-being and well-being adjacent topics, uh, since that time. Uh, I've been chair of the ASA's Committee on Physician Well-being, uh, for about 5 or 6 years. I am the immediate past chair, which I'm quite happy to say. Um, also on the board of trustees, the Massachusetts Medical Benevolence Society. Um, I love trail running, often falling, um, with my dog, um, and then begrudgingly hiking from there on, um, piano, guitar, and spending time with my wife, son, and dog. Now, to start things off, do you know where the echo is coming from? Yes, please. I think it's coming from the computer. Before Matt gets started. OK. So much better. All right, and I'm so glad because um Matt has been so gracious to tell us his story, um, and his journey. So, uh, Matt, without further ado, thank you so much. Thank you, Amy. Good morning, everyone. My name is Matt Hitron. As Amy said, I was born here in Boston, grew up a suburban white kid with all of the, you know, privileges and unfounded sense of entitlement that perhaps that entails, but, um, I, uh, during my internship and residency in, in medicine and really towards the start of my fellowship, I developed a raging opioid addiction. Um, It was pretty surprising to, to me and to a lot of people around me. Um, they didn't know until it, until it came to light, and I've done obviously a, a lot of postmortem in, um, recovery since then. It was 2009 that I entered recovery and I've been in recovery, of course, ever since. Um. During that period of time, I was, you know, underemployed. Uh, I drove a taxi, I was out of medicine, of course, um, did some tutoring, but ends weren't meeting very easily, and so, um, I had a young child at the time. Uh, my wife was a teacher, still is a teacher. She's a librarian, and I actually got help through, um, a couple of different, uh, organizations, namely PHS and the Massachusetts Benevolent Society. Um, PHS was a real salvation for me. Um, PHS, for those who don't know, physician Health Services, and Folks with whether it's substance uh um use disorder or um other behavioral challenges can contract with PHS and PHS serves as a liaison between the client, someone like me, and the, uh, the board of medicine. Um, it's, it's a very interesting relationship because They're not exactly an advocate, right? You have to do your part, you've got to follow the contract, but, and so they really serve as a monitor, um, but they are your, your voice to the board, and they give a, a, you know, they represent you and uh can attest that you are following the guidelines and that you are on track, um, which is a really important position. Uh, for them, and ultimately is what, you know, I, I, I had a very successful path, uh, you know, through PHS and with the Board of Medicine, um. Ended up, the practice of medicine was not for me. That was probably a big thing that led to my addiction in the first place, and I, I think I got very lucky in a lot of ways and discovered this career in, in biotech that, uh, honestly, going through medical school and, and training, I didn't really know existed, didn't know how to get into it. I, I still wouldn't know how to tell somebody to get into it, um, sort of happenstance, the way different people get into this career. Um, but it's worked out very well for me, and, uh, I feel very, very blessed and lucky to have, um, Um, found that path. The other support group that was really critical for me was the Benevolent Society, and the Benevolent Society, you know, I, I engaged them through PHS. So, many clients of PHS are put in touch with the Benevolent Society because, you know, it's a, it's a pretty, um, acute and distressing time in a person's life to, to lose their, you know, income and to lose their potentially projected source of income for a long time to come, right? Something that you've worked very hard for, and all of a sudden, the prospects of whether or not you'll be able to do that is, is gone. Um. And so, I was able to get financial help from the Benevolent Society to sort of bridge some gaps before I was able to, to sort of, uh, uh, find this other path that that was really better for me overall. Um, and then of course, I was able to give back to the Benevolent Society and, and have since joined as a trustee, as, as Amy has mentioned. So, um, it's really come full circle for me, and I Spent a lot of time. I talk about twelve-step programs with kids at Tufts University, uh, in their medical schools, usually first years. Um, and I think it's, uh, substance use is, is uh underappreciated. Uh, area for doctors, right? The, the cliche is that, uh, you're, you're only an alcoholic if you drink more than the doctor, right? And, uh, you know, clearly that's, that's not true, and statistically, either, you know, someone in this room or listening online is engaged in, in substance use at a sort of, um, at-risk level, at, at a minimum. So, I think, you know, when I was coming through training, having a um a way out was, was what I really needed. Someone to talk to. It was, it was entirely secret, and I remember pacing around in my backyard thinking, how can I get out of this? How can I get out of this? Trying to self taper myself, uh, off opiates and getting to the end of the bottle, and withdrawing and starting all over again. So, Having a, a, a way out and a, and a very clear path, I'm the person to talk to and we can keep it confidential and figure out the right way to get you help. Um, having those resources is, I think, vitally important both for, um, physicians in training and then, um, you know, early in their, in their practice. So, I know I'm right about that 5 minute mark, so I can pass it on to others and we'll do questions at the end. Does that make sense? Sound good? Anything else I should comment on? Good. Thanks everyone. I just want to offer my heartfelt thanks to Matt for doing that. Um, it's not easy to get up in front of a, a group of doctors, um, and talk about something that personal, especially a group that, that you don't know as well. Um, so, my heartfelt thanks to you for sharing that because one of the most important things, especially about a topic that's so stigmatized and quieted down is, is understanding that you're not alone. So, if, if anyone In this audience, either today or, or watching it later, um, needs help, please know that any of the resources we talk about today exist because they should be used. So, um, there's nothing wrong with you if you reach out for help. Um, uh, contrary, there's something very, very right, um, and, and it's a very courageous decision to reach out and ask for help. We're talking about well-being, and we're talking about medicine and a career in medicine, right? It's a hard job. Nobody went into medicine thinking it was going to be an easy job. Um, it's nothing new that it's a hard job. It's always been a hard job, it'll always be a hard job, just the nature of what we do and what we commit to doing is difficult, um. In the year 1900, roughly, Sir William Osler, who many consider to be the father of modern medical education, said to a group of medical students, in no relationship is the physician more often derelict than in his duty to himself. They were all men at the time. Um, we're still talking about that now. Self-effacement, self-sacrifice to, um, an unfortunate level. He also told them to begin at once the cultivation of some interest other than the purely professional, so, work-life balance, um, balance of some sort, well-roundedness, that sort of thing, attending to yourself as a person. It's nothing new. We were talking about this in formal medical education 125 years ago. So I wanna take a moment right now, um, and talk about what it is that we do. Um. Because we have a profoundly sacred job. We take care of people who need help. We take care of people in their most vulnerable states. Um, and I'm not just talking about the patients. Uh, for those of you who are parents, you know there is no more vulnerable feeling than having a child who is sick and needs help. Um, And so, we enter into that space, and sometimes things go great. And sometimes things don't. And sometimes things go as well as could possibly imagine, but you can't get the situation of that child and their family out of your head. Um, and that's the toll of what we do. And so, the fact that there is an emotional toll, the fact that there is a burden to that, that, that there is some work that we have to do on our end to maintain our humanity through that is expected and it's normal. Um Sad things happen Sometimes sad things outside of of, of medicine. Um, I know many of you in the audience lost a friend this, this week. Um, uh, a resident at Mass General, um, died unexpectedly this week. Um, and while his family wants everyone to know that it was not intentional, um, that doesn't change the, the grief and the hole that's left in a lot of people's hearts about that. So if you're Um, dealing with that right now, if that's very close to your heart, uh, please know that there are, uh, people here to support you. So what is the burden of mental health in medicine? This was a nice synopsis, um. That, that, that was published shortly after the COVID-19 pandemic really came in full force and we started talking about mental health care because I think that, the, the burden of what we do was laid bare so clearly um for both ourselves and the lay public through the scenes of the, the early pandemic. Um, So gratefully, we started talking about mental health care in a more open way, which is a wonderful byproduct. As it turns out, we have similar rates of the more common mental health concerns as other professions. Similar rates of depression, similar rates of anxiety, we're not superhuman. Um, and while looking at mortality, we have actually, um, lower general and cost-specific mortality from, from illnesses. There's one outlier, and that's suicide. We in medicine have higher rates of suicide. Um Why? Why is that? There have been some people who have Postulated that maybe we're better at completing it. You know, we have knowledge of medications, we have knowledge of physiology, we have, uh, the, the skills to access potent medications. Um, there is a lot of stigma surrounding seeking help. And that stigma is both sort of, uh, manufactured in our minds as well as very real and cultural and also very structural in terms of some licensing requirements. Hopefully, that's changing. There's also hubris. We feel that we're superhuman. We're doctors. You know, we're, we're nurses. We're, we're, we, we, um, are beyond that. We help, we don't seek help. Um, I will say that a review of suicides in 2019 did show that anesthesiologists and surgeons topped the list. Uh, followed by psychiatrists and GPs in terms of highest rates of suicide, although, These numbers have never been truly studied well, um, mainly because a lot of deaths are sort of shrouded in mystery and secrecy. Um, I'm gonna get to, back to that in a little bit. But when I mentioned licensure, when I mentioned stigma around mental health care, one of the major things that has been a barrier is issues of licensure. Um And, and just to take a moment right now, I'm gonna talk a lot about physicians, because that's where the data lies. But if you're an advanced practice nurse or a nurse, please know that most of what I'm talking about today, uh, extrapolates. Um, so, please don't feel I'm leaving you out. This is just where a lot of the data lies. But issues of licensure in medicine in particular, um, the AI for Microsoft gave me this lion when I put licensure in, and, and at first I was just kind of curious about why that is, but, but it is a formidable, um, you know, dangerous, protecting, scary thing. Um. So what is the issue around licensure? Well, the issue around licensure, if you remember filling out your medical licensure thing, they would ask you questions like, do you currently have any health conditions that impair your ability to care for patients? And you're like, no, no, I'm all set. Have you ever been treated for a mental health care condition in your entire life? Well, Well, I did have depression in medical school. I was a little anxious and so I took an SSRI for a year and got off of it. I just needed to help, yeah, no, and you have to fill that out every single time you renew your license. That's a problem. That's a barrier to getting healthcare. In fact, the Federation of State Medical Boards in 2018 recommended many things. Please do not read all of this. I've got a next slide that says all of these big words mean. Um, but what they ultimately recommended, among other things, was. That to use the language, are you currently suffering from any condition for which you are not being appropriately treated, that impairs your judgment and or that would otherwise adversely affect your ability to practice medicine in a competent ethical and professional manner? Yes or no? That's it. It gives parity with mental health care and physical health care. It's incredibly important. A lot of those words boil down to 4 major recommendations from the FSMB. Ask only if impaired, so don't ask if, if you have any conditions whatsoever. Ask only if you have any conditions that impair your ability. Ask only if they, these are current conditions. Allow for safe haven reporting. What does that mean? That means that if you're appropriately engaged in and following the recommendations of a physician health program, they do not have to report you to the Border Registration of Medicine. That's critical, cause that's a whole other level of getting your license back, um, after you've gone through treatment. And include supportive language that normalizes physician wellness. This was in 2018, so how are we doing? A recent study that was, um, that was senior authored by a, a, uh anesthesiology colleague of mine, Bridge Pulos, um, looked at this and looked state by state, how are we doing? Not great. These are 4 little recommendations for the, the, the medical boards of each of these states. There are only 3 states that are currently fully in compliance with those recommendations, all 4 of them at once. OK. We're not one of them. We're close. We're really close. We're actually doing pretty well. This is for physician renewals. This is uh licensing renewals, and this is for first time. Again, not doing great. And this is very recent data, OK? This is 2022. 4 years after the FSMB recommended this. Um, this this is the change, positive or negative towards those recommendations over time. So, it's really kind of all over the board. This is an area where we need to make improvement. And that brings me to physician health services. Physician health services, as, uh, Matt mentioned, can be absolutely life-saving. It can be career saving, um, can be very scary, and I would recommend that anybody engaging with PHP do so through our Office of clinician Support, um, do so with a liaison. Um, that being said, if you want to reach out to them directly, you can also do that. Their numbers here. There's a QR code that brings you to the website to learn more about them. A year and a half ago, some colleagues and I surveyed all the physician health programs in the country and in the Canadian provinces. To ask about, you know, what are the barriers to folks engaging with PHPs because a lot of times, um, and I'll talk about the Massachusetts Benevolent Society in a moment, a lot of times folks face real financial barriers towards either the the initial engagement and evaluation phase with PHP. Or following the recommendations long-term. And so we asked about that and what we found was not surprising, and it's that there are financial barriers to evaluation. There are financial barriers towards full engagement with PhPs and those tend to be worse the younger you are. Medical students have the highest burden of all of them. Um, there are a number of PHPs who are working with their state legislatures to have the, the insurance that's provided to physicians cover these services, um, to remove one of those barriers. But again, it gets to be a very tricky spot for our younger colleagues. So that brings me to our situation in Massachusetts. I've said this, this phrase a couple of times now, the Massachusetts Medical Benevolent Society. What the heck is that? You know that Matt and I are both trustees of it. Um, I've had the honor of being a trustee on it since around 2012, 2013. Um, Mark Rockoff, who, uh, was previous vice chair of anesthesia, is currently the president of this group. Well, this group exists under the Massachusetts Medical Society and is supported, um, in part by the Massachusetts Medical Society. It is a 4013c charity. Um, so it is supported largely by donations from the public and from, um, smaller, uh, regional medical societies. It was established in 1857 and has existed in perpetuity since then. To provide for Massachusetts physicians and now we've sort of um dipped into physicians in training, so medical students who are in quote, reduced circumstances. Right, so it's very 1850s language in our charter. Initially, a bulk of what they did was provide for um Civil War veterans, field surgeons, uh, and their widows and their children. More lately, in the last couple of decades, we've engaged very closely with the Massachusetts Physician Health Program. We get a lot of our referrals from them and the, the organization offers grants to people who need financial assistance. And these may be for um Ongoing treatment, therapy, drug testing, if they're in, in monitoring programs and have yet to regain their Massachusetts license. Um, these could be situations of mental illness. These could be situations of, we've, we've had people in who have had issues with burnout, um, who've had to take a step back, and we've been able to support a number of physicians back into full practice, um. Or back into a new practice or a new career that makes more sense for them. Um, if you want to explore more about this organization or if you feel led to give a donation, um, feel free to, to click on the, the QR code there. You can find referrals for how to get engaged. Um, we have, it's all very confidential how things are managed. Um, we have, uh, several social workers that we work with closely to help us, um, help these, these physicians. And of note, when we did that survey of PHPs, there are only 3 states who have anything like this, uh, that was part of the impetus for us doing this survey. Um, but it really does stand unique in, in its function, um, that it's, that it's an organization that has been in such perpetuity and that actually does function to help so many people, um, each year. More locally, the Office of Clinician Support. Everyone should know this, um, this resource. If you don't, welcome to it. The Office of Clinician Support is run through the, uh, the Department of Psychiatry, um. Offers free and anonymous counseling to any clinician at Boston Children's Hospital who needs it. I will never know. No one in your department will ever know if you reach out for assistance there, um, but they can often help you through a rough patch. There are other resources for folks at Children's. Many of you have seen posters similar to this, especially in, if, in, uh, call rooms, um, and it basically says that there are a lot of people here for you. There's a lot of resources available to you locally, statewide, nationally, um, and there are many reasons to call them. Again, nationally, there's a lot of resources for well-being. The National Academy of Medicine has a collaborative on clinician well-being and resilience that is, um, encompasses more than 200 societies and organizations in medicine. Pretty much anyone you can think of is a member of this, um, working towards addressing well-being, um, as As a way to really ensure the sustainability of the workforce at the end of the day. Um, and if you look at this compendium of resources, you will find everything from individual resources for building individual resilience and, and wellness, if you will, to Policy level things that can improve well-being. Things like licensure, things like the Lorna Brain Act, the Libya Zion Act. One thing I want to mention that everyone should know, there's some cards out there if you want to grab some on your way out. We used to have a National Suicide Prevention Lifeline. It's a big long confusing number and you had to post it up everywhere. Um, that has changed in recent years. Uh, around when COVID happened, around 2020, this rolled out, um, nationwide, and now I believe every state has this number in place. If you're having a mental health crisis or feel that you're gonna harm yourself, you can dial 988 the same way you would dial 911. And you will be connected with someone that can help you. And they can hook you up with future care down the road. Future directions here. I just wanna put a couple plugs, um, for, for future directions, um, wellness interventions you may see coming down the pike. If you're in anesthesia land. Um, you're gonna be getting a survey today. Sorry and thank you. Um, I, I send you guys a lot of surveys and I do appreciate everyone who fills them out. Um, they don't hurt you, I promise. Um, the one being sent out today is a new metrics that, that's being developed. Um, it was developed by a colleague of mine at, uh, UCLA and it's meant to be far more functional than something like the Maslock burnout inventory that just says, well, you're burned out. Congratulations. Um, this one is far more focused and, uh, attentive to the actual aspects of our job and our work life that can impact well-being and it really will break down where we need to put most of our focus. Um, it's in the external validation phase and we are a site. So, if you get that survey today, please fill it out. I swear it won't hurt you. Um, and then for everyone involved here, we're going to be having an art installation, essentially. Um, it's a collaboration between an architectural firm that does a lot of interactive art installations and, um, immersive design systems, which is our, our simulation center here. And it is basically going to be a digital board with a bunch of ticker tapes that you can text messages to, to thank your colleagues. And when you text your gratitudes, it's called the gratitude canvas. When you text these gratitudes to the board, they will pop up for everyone to see. It'll be by the front desk. And it's a way for us to show gratitude to one another, OK? And it'll just stream throughout the day, various gratitudes from people to people in an attempt to Elevate us, uh, improve our, our mood, improve our sense of community, um, and we're also gonna be sending a survey about that too. So, um, thank you, uh, for that in advance. So, without further ado, um, thank you for your attention. I'm, I'm gonna turn things over to Doctor Buck Miller now. Great. Well, thank you so much, Amy and Matt, for your introductions, and I think it's so important to have a multi-pronged attack, if you will, um, to this issue. So, I want to focus on supporting recovery after an adverse event, which is a critical component of physician well-being. And as Amy mentioned, I've had the, the pleasure of serving on the wellness committee through the American Pediatric Surgical Society, um, for 8 years now and was the chairman over the past 2. And I want to credit really the work of the entire community um that is on this committee and particularly Lauren Berman, who is the current chair that uh helped put this slide deck together for all of the committee members to take to their institutions. So, the goal of the next 10 minutes or so is to describe how peer support can help clinicians recover after an adverse event. To advocate for ongoing peer support, uh, from individuals, our departments and institutions, and then introduce to you our APSA peer support program. Well, the impact of a medical error on practicing physicians has been well studied for many decades. There are many, many articles in the literature, and really I think the take-home point of this is that we're not immune. None of us are immune to this event. Um, over 90% committed a medical error throughout their careers, and over 90% had no support from their institution. This is historical data, which I'll show you has improved slightly, but this is 20-year-old data. So this has been on the radar for quite a while. And why this is so critical is there's a direct link to almost doubling the potential for Uh, suicidal ideation if you have suffered through a, um, medical error or significant event. So, there's a definition that you may be familiar with called the second victim. This is when a healthcare provider who is involved in an unanticipated adverse patient event experiences psychological and or emotional trauma that is related to that event, and that is termed the second victim. This has been utilized really almost over 20 years, but as the wellness has become more and more visible, Uh, we often refer to the second victim. The APSA Committee, uh, sent out a survey, and many of us get these surveys and you wonder whatever happens with this data. This was actually a foundation for 3 papers that we did through the committee looking at some of these issues for specifically our profession in pediatric surgery. So, a simple question, um, have you ever experienced a medical error that resulted in patient harm or, or death? And it was over 80% of us had. And the next question was, how did you feel supported? Only 25% were satisfied with their institutional support in the wake of an error. So there's certainly a dissonance there that requires being addressed. Well, who is at risk for the second victim syndrome? Surgeons and anesthesiologists topped the list. Followed by uh OBGYN and pediatricians. Female providers, we're more at risk, trainees and cases that involve a medical error and an unexpected adverse outcome. One's potential experience as this being the first time you've gone through it, or if you have a special connection with the family. These are all things that increase our risk. So, we asked the question and asked for a lot of free-form answers, but some of these may resonate with you, some of these answers after an adverse event. There's no support. It doesn't matter where you work. We feel like I'm getting thrown underneath the bus and no one wants to get on the bus with me. Colleagues are often very well-meaning but don't know what to say or don't say anything because it's a very sensitive topic. And I think if you think about those themes, there's a lot of validity and I think we've probably all experienced those. So, what helps us recover after a medical error? Talking about it? Forgiveness for ourselves, dealing with our imperfections, learning more, jumping in there, becoming an expert so this will never happen again. Helping others, teaching, and then preventing recurrences and working on the teamwork. All goals that are always being done in the background, but very important to keep stating them. And Another survey that was done, particularly among pediatric surgeons, said, who do you actually want support from? Well, we want support from other physicians and other surgeons, people that are like us, people that understand what we've been through. Yes, we can get it through mental health professionals, and that may be very appropriate and, and a reasonable thing to do, or through the employee assistance programs, but we actually want it through other uh surgeons. Well, we asked this question specifically within APSA, and again, only 11% said, I don't wanna be contacted by anybody. I'm good. That tells you the opposite. 90% people do. They want to be contacted by surgeons in their practice or other physician colleagues, and about 40% would want to take part of their institution's, uh, peer support program. Well, what is the whole goal of peer support? It's to take us through these stages that are inevitable in the recovery and moving us from either dropping out of the field or just surviving the adverse event to a, to thriving and getting back, uh, to this wonderful profession. Well, it's hard to reach out, and I just wanna take a second to read through some of these. I may be thinking, My colleague may want some time to process this when they're actually thinking, I really feel isolated and I feel alone. Well, we should maybe lessen the caseload, take a little bit of the burden off. That person may be thinking they've lost confidence in me. Everybody knows I made that error, they don't trust me. I don't know what to say. When that person just really wants to be treated normally, they don't wanna be avoided. And you also think, I don't wanna ask a question. I don't want them to relive that situation over and over. What we're really thinking when you've been through this, I can't get it out of my mind. That's all I'm thinking about. So, you see this, this has to be balanced, and that can be something that is done through peer support. I'm not gonna read through every one of these, but in general, what is peer support? What it is not. We're not asking you to be the therapist. We're not asking you to provide the counseling, and it's, you're not there to do an Eminem on the event. You're there to be for the person. You're not there to drill down the details of the event. You're not doing, correcting the facts. You're not cheering up saying everything's gonna be OK. Peer support is actually sitting with that person and providing the first aid to the emotional state and the, that event that they're going through, not only in the acute period, but this continues and everybody here knows it to that subacute and potentially chronic period. And importantly, we want to normalize our reactions to going through these events and I think Amy brought up that point to you. We have to bring this out in the conversations and make them normal to talk about it. So, some of the, and I'll talk about some of the training that is done, but again, what we want to do is introduce the situation, explore how the per meet the person where they're at, normalize the situation. You can use some phrases like this is very understandable that you would feel this way. I've faced something like this before and I've felt this way. And the ABSA Wellness Committee has, uh, participated in 3 separate, we call them little APSos for those of you that aren't pediatric surgeons in the audience. But these are online resources done by leaders in pediatric surgery that are walking through these issues. These are about 15-minute or so little snippets looking at moral distress and peer support by one of our former APSA presidents. The second victim syndrome, uh, how peer support can help, and then how to conduct a peer-support encounter. So, these resources are available on our, our website. So, it's important to know how to access the support. All of our speakers have talked about that. That can be done through a peer support program, an employee assistance program. And I've often even asked the question for our own institution, if we have an uh an unforeseen adverse event in the operating room, we fill out a Sears report. Maybe that should also trigger some emotional first aid to those of us that may have been part of that event. It's always been something in my mind rather than just kind of waiting organically for it to come to light later, so something to be thoughtful about. Uh, another issue is many institutions and departments have developed very formal peer support programs. I think it happens. I think we're friends. I think we care about each other and talk to each other. But there is a benefit to formalizing a program within your department. And one of the resources that our wellness committees uh provides is that several members that are the head of their departmental peer support programs have templates, have primers, so that you don't have to go back to your institution and start from scratch. And I think that's a really critical, uh, component. And then beyond our institutional peer support, what about organizational support? So, what I'm specifically talking about for the pediatric surgeons is what APSA has provided. And this was really an early vision of Kurt, Lauren, um, that led this initiative. I was very involved with this as well. And we rolled this out after we went through all the appropriate channels through APSA, the Board of Governors, to provide this resource for all of the pediatric surgeons. Um, So, where can you find this and what does it look like? Um, so, the ABSA peer support program is supported by, uh, the Board of Governors. It, it functions with all the tenants that I suggested. It's not there to be an M&M, but it's there to support the person if there's not an institutional resource or if people don't feel comfortable, um, going through their institution. And so, here's our homepage. You can see right here, um, with the resources, it's a drop-down list to resources, and then over here, you see a tremendous number of things, but the peer support program is listed here. And what does this look like? There's an an online intake form. You can refer yourself or you can refer a colleague as well, and it gives you that option in this support program. And what is important is, uh, we've looked at our experience over the past, it's been going about 2 years now. There's 1 to 2 referrals per month. About half of these are self-initiated. The remainder are initiated by colleagues. We have a less than 24 hour response, uh, to reaching out to the person involved, uh, in the event. The two major themes of asking for peer support have been uh support through adverse events and or toxic work environment. All referrals were completed, and I think this is critical that no one refused support. Well, who are the people that are doing the peer supporters? There are actually 50 people that have been trained through apps, and you may have seen this at the annual meeting. There's always sessions and breakouts to refresh this training. Um, it's very extensive. There's a lot of effort that goes into these national peer supporters. And, uh, virtually all of the people that signed up and went through this training in this program feel very prepared to help provide this peer support. We do a lot of online training, a lot of, um, video sessions to keep these skills, uh, tuned up. And 80% use these skills in other venues. This is obviously very protected. Again, uh, like Amy said, it's very critical to know that this is all anonymous and this is not reported. So, in summary, um, complications, they're inevitable, but they can be devastating not only to the patient, but to us going through this process. And how do we support recovery? We wanna provide, and the whole reason for this grand rounds for which we're very grateful is to support the culture change. We're moving there. We've been moving there for a while, but you always need to keep Effort in this space. Um, we wanna encourage conversations. We want to consider developing departmental and institutional programs which are being done in all of our departments, and then also utilize organizational programs if that's what space you feel most comfortable in. Um, Amy brought up so many of the resources that exist within the state, but if you want your peer support through someone that's actually doing your job and living what you're living, I'm very proud to say that ABSA has that, that support for our pediatric surgeons as well. Um, so that concludes my comments. I'd love to invite my colleagues up and, uh, join if there's any questions, um, from anybody listening in person or on Zoom. So thank you very much for your time. All right, thank you all. We have about 10 minutes for questions or comments. Or stunned silence. OK, here we go. Thank you, um, and thank you to the three of you. Can you guys hear me? Yeah, um. I'm curious, you mentioned the questions that go into the board, um, credentialing process or licensure process. There also is nowadays a lot of stuff online and family search, and so I'm wondering what reentry looks like for somebody who's gone through substance use disorder or something and has recovered and is looking to get back into medicine. How, um, what kind of regulations are there or guidelines are there about disclosure, about, um, mandatory, uh, uh, you know, uh, reporting, things like that? Um, so, the question is about re-entry and family searching things up online and, and finding things and, and disclosure. Um, engagement with PHP is anonymous, OK? Um, none of that stuff's gonna be disclosed to the broader interweb. Um, That the reason why the FSMB recommendations are so important is because they include the aspect of safe haven regulations, which means if you are engaged with the PHP and you're following the recommendations. It will not be reported to the Board of Registration of Medicine. Your license will not be revoked or suspended. OK. And Once you go through the program, you can either work with your prior chair if they're amenable or group lead in private practice, um, and, and develop a re-entry, um, agreement. With monitoring and what have you if it's substance use disorder, um, to get back into practice. OK. That's ideal. Unfortunately, sometimes these things come to light because laws are broken. Diversion, what have you. You know, um, driving under the influence, that sort of thing. Um, in those situations, those arrests are a matter of public record. Those things do have to be reported to the Border Registration of Medicine. They don't fall under safe haven guidelines. Um, and that is a difficult thing when families could find that, um. You know, uh, Yes, please. Yeah, um, I was actually in a very tricky situation where my uh addiction was the result of, or I was diverting and was uncovered. That was discovered and I had some legal issues, you know, and again, I had a very lucky path through things. Um, and the board was very, you know, wanted to work with me, was willing to work with me, and sort of had a very Relatively clean path through returning to my license and, and I had a job and was gonna go back to the practice of medicine when I thought, you know, uh, uh, discovered this other career path and then realized this was better for me. Um, but I was, I was anticipating that discussion with patients actually, and In my case, I was looking to a career in primary care, and I would have, I was actually thinking it would be a very humanizing and, um, sort of, uh, uh, bonding, uh, type of disclosure that, you know, I had a substance abuse disorder and, uh, you know, was treated and, and I'm now practicing again and and under monitoring and, um, So that that was something that was foremost on my mind and, and I had fully planned to practice with that type of approach, disclosing to patients and sort of seeing if it would, how it would impact my relationship. OK. Any other questions? Nope. And I'll just add it's, you know, the, the benefits of self-reporting clearly outweigh the, uh, you know, sort of other approach. Oh, I wanna answer this one. OK. Criker suggests that after a serious event, one does not discuss it outside of Eminem. How can you ask for help and keep the events from being discovered? So that's a question being asked online. This question has been asked a number of times. Um, I have spoken to scores of malpractice attorneys on both sides, and, um. Couple things here. Kriko has to say this. Kriko absolutely has to say this. When you reach out for peer support, however, and when you are providing peer support after an adverse event. It is not to discuss the details of the case. It is to discuss the emotional impact of those events. Do not put anything in writing. Do not send a text message that says, hey, I wanna talk about this event that just happened. Do not send an email to the same. Do not write a letter. So they might do that. Um. Call the person, walk up to the person. I heard you had a bad day. If anything needs to be written, make it as vague as possible. As a peer supporter. We are all used to memorizing things, right? There is that button, that, that flip, that switch that we flip in our head of we're in memorization mode. Turn it off when you have that conversation. Do not, after the conversation, go through it in your head and be like, OK, now what exactly did they say? Let me remember exactly what they said. Try and get it out of your head. You're a peer supporter. You're not there to hold their memories forever. Listen to them, provide support, let it go. Now, the, the malpractice attorneys I've talked to have said, especially the ones, um, on, on the, the prosecuting side, if you will. have basically all said they would never put a peer supporter on the stand. Who would humanize the defendant. Why would they do that? They want to portray us as heartless, not caring, not vigilant. They would never put someone on the stage who would potentially humanize the defendant to the um to the jury or to the judge. So, to my knowledge, there has never been a peer supporter called to a witness stand in a malpractice case. It's not that it couldn't happen. It is absolutely discoverable, so don't put anything in writing. But the chances of it causing Medical-legal harm are infinitesimally small. Um, The benefits of seeking peer support, of preventing suicide, of preventing loss out of the workplace are extremely high, and high yield, and that is supported by data. So, I would never discourage peer support. Yeah, I can't emphasize that enough. That was actually the biggest sticky factor we're going through ABSA. I'll be honest with you, to, uh, for peer support because we were asked that question, would we be liable as an organization, as individuals, and I can't state enough, um, it is discoverable what the conversations are, but the point again of peer support is not to look at the details of an event of an adverse event. That's, uh, very critical. And then also, you know, we've asked the question to, um, Mark Hoffman is actually a pediatric surgeon who's also a, a lawyer and works in this space. I, this is years down the road when anything would potentially ever come up and there's been absolutely no instance ever where any peer support um has ever come to, uh, you know, basically a courtroom. All right. And that's, that's really critical, but it is discoverable. So we have to just kind of balance that with that caveat. There are also a number of constructs to get around that. Um, you can, you can define it as, um, you know, a encapsulated within a debriefing or or what what have you. Um, there are also a number of states who have tried to pass through the legislature that peer support in the medical setting is non-discoverable. Um, and I, I fully support that sort of policy level change. I, I just wanna thank you all very much. I, I'm sure Steve's not here, but obviously expressed the extreme support of the departments and foundations for the work that you're all doing. So thank you very much. I guess, Matt, very briefly, I know we're almost out of time. Um, addiction is just so vexing to try to treat appropriately, etc. and it seems like most of the time it requires some motivation on the part of the person to actually want to get better, um. You're speaking to a bunch of people this morning and we have high risk addiction problems within our specialties. Um, could you just say, were there certain things that people in our position said or did not say or things that people did that was, uh, helpful or unhelpful to your journey to try to, uh, become, uh, outside of the addiction world. It's a great question, um, because I, we, Amy and I were just talking, uh, after she finished her, her part that things have changed so much, right? I was in medical school 2002 to 2006, residency 2006, 2009. Um, I was writing, you know, uh, uh, 30 oxycodone with 3 refills, you know, for, for whatever. Um, uh, that pain is the fifth vital sign. At the same time, so that there was a very a culture of sort of normalized, uh, opiate use on the one hand, um, that we should be using them. Um, thank you, uh, you know, Purdue Pharma and all the Sackler family. The, the second thing is that, um, there was, uh, at the same time. You know, uh, eye rolls at drug seeking behavior. So admissions, there's, you know, frequent flyers in the adult world that are, you know, clearly drug seeking behavior. And so addicts and addiction was, um, you know, a, a, a bad thing and, and not normalized in any way where, when, when I was training. So, I think the compassion approach for, for both patients with addiction. Um, is, is a critical piece, and I know that certainly prevented me from seeking help. I, I, I wanted to defeat this on my own. I did not want to involve others because I did not want to be labeled in the same light as we labeled patients that would come in with addiction and, and, um, you know, quote, drug seeking behavior. So that was, uh, the, I think the way that we treat our patients with addiction goes a long way to, you know, Uh, uh, allowing ourselves to become a patient with addiction. Thank you again and thank you again. I know I've said it several times now, but it, it means the world that you presented your story today. Any other comments or questions before we get back to work? All right, thank you.