Dr. Eman Khadra Ansari - Feeling Hot, Hot, Hot: Global Warming & the Medical Team

Uh, pediatric critical care at our institution and subsequently went on to a Pe's uh pulmonology and critical care Fellowship here. Following that, she served as a staff member in Cincinnati for 5 years before returning to Boston Children's Hospital where she served in a variety of roles, but notably on the sedation service as well as an attending in the emergency department. In 2016, uh, owing to her ongoing work in medical education, she was appointed a scholar, uh, at the Boston Children's Hospital Academy. Uh, please join me in welcoming her to the podium today. Thank you. Thank you. So, um, some of you, um, were my teachers when I did my critical care, uh, fellowship, and, or my bosses, and, uh, remember my last name as Alhadra, which is, um, my maiden name. So when I became a US citizen, I thought, how about I make it an easier name, my husband's last name, and I changed it to Ansari, um, but it didn't turn out to be that easy because every time I introduced myself as Doctor Ansari, The response would be, you don't have to be sorry, ma'am. So today I'm gonna talk to you about uh something that is warming up, but what is warming up is not only the globe, uh, but also um there is an issue of burnout in medicine, um, and surgery, um, and all, um, disciplines in, in medicine. Um, the topic of humanism and professionalism has become a hot topic in medicine over the past decade or so. And in it, burnout um is becoming uh the front and center topic lately. So, um, I don't know if a lot of you know, but we do have our very own Institute of, of Professionalism and ethical Practice here at Children's. It was established in 2007. Uh, the Brigham has one, New England Journal of Medicine and JAMA have been increasing their focus on the issue of professionalism. It's considered a new wave. Now, uh, JAMA has a series on professionalism as well. Um, and the topic of burnout, as I mentioned, has becoming increasingly a topic that we discussed in medicine and about medicine, um, like, uh, this article from the Boston Globe. And this one and this one, you will be seeing it a lot. Vivek Murthy, who you all know, was our surgeon General until recently, now that he no longer is the surgeon general, he's turning his focus on the issue of physician well-being. The term burnout is becoming a bit of a charged term and it's a negative term because we're talking about the bad thing that's happening. So, the flip side of it or focusing on the positive aspect of things um is the term well-being. So focusing on physician well-being is basically a synonym to trying to combat burnout. And this is now his focus. He's seeing it as a very important issue to focus on. Why am I focusing on it? So, that's a question you may ask. Um, I did a couple of years ago, a faculty fellowship here at Boston Children's on humanism and professionalism, and I was interested initially in patients with low English proficiency, but very quickly noticed that the issue of burnout is also an issue of importance, so I started reading literature about it and came to this point. So, how big of a problem is burnout? Um, at any given time, 1 in 3 physicians are experiencing it. Physicians are twice as likely to be dissatisfied with work-life balance or integration compared to people in other professions combined. That's pretty big. And then um in 2016, New England Journal of Medicine conducted this Catalyst survey, 570 physicians responded, and 96% of them said that um burnout is a serious problem. So that's, you know, the gravity of the problem. They think it is a problem. 65% think it's a serious problem in the healthcare industry specifically. However, only a third of them think that it's a problem at their institution. So their institution is perfect, but it's, it's happening at other institutions. So a bit of no ownership. And when they were asked about what are their institutions doing, and this is like the New England Journal of Medicine asking everyone, it's not about Boston, it's not about Boston Children's only, this is national. Um, they're saying that the organizations are doing nothing or not enough or paying lip service about it. Um, they're talking about the problems in committees, but so far no action, um, has been taken. This is in 2016. Because we're a healthcare team, we're not only physicians, we're physicians, nurses, respiratory therapists, social workers. I tried to see if there's any data about the other healthcare providers with us. Nurses had some studies on the issue of burnout, and the rate varies from 10 to 70%, which I would expect to be true because part of the factors that impact burnout is lack of autonomy, um, or decreasing autonomy, and that's one of the reasons why us physicians with now more guidelines and more cookbook approaches to so many things, um, we're having increased burnout. Nurses were taking a lot more and more out of their autonomy, so their rate is pretty high. Um, Physicians were about 50% and there's more data on physicians. Almost no data on social workers, respiratory therapists, and other workers, um, uh, in the healthcare team, but this is an area of research that some of the, the residents might be interested in. So what is burnout? Is it like something new, something old? Burnout is basically a syndrome of three main symptoms exhaustion, loss of enthusiasm for work, and these are things that are not like part of your character. You've always been tired. You've always been exhausted, but you still deliver. No, this is something that is a change, a change that happened over time. Similar to cynicism, some people are cynical by nature. Well, I'm not talking about those people, I'm talking about someone who used to find value in being in medicine, this is a great profession, and lately is becoming cynical and unsure that what they're doing is really worth it. And doubting um uh low self, low sense of self, of personal accomplishment. So we all, when we, like, I can talk about myself, when I came to Harvard, had this imposter syndrome. Am I good enough to be here, etc. Again, that's not what burnout is about. What burnout is about, you know you're good, you You've been here for a while, you know that you're doing a great job, and over time you start doubting yourself. Maybe I'm no longer good, maybe I'm not good enough. Um, so it's a change that happened over time. You're exhausted in the morning, you're not sure about the purpose of your job anymore, and you're not sure that you're good enough anymore. Um, burnout is usually regarded as the result of prolonged stress, and some people try to see what's the difference between burnout and depression. Typically, depression, we think of genetic factors that make you susceptible, acute stresses that push you over the edge, um, versus burnout, we tend to think of it as something that happens over time. It's like the Indian, uh, known story of the frog that if you turn The heat on the frog, the frog will jump out of the water, but if the heat is slowly increased over time, you can cook that frog. So it's over time we're being cooked, basically. That's the concept of burnout. So it's a chronic stress that doesn't push you into depression acutely. However, over time brings these symptoms of burnout and of course burnout, if not attended to, can lead to depression and can lead to The consequences of depression. So I'm gonna keep it light, we're still in the morning, so I'm gonna stay on the positive side. How to beat burnout. The group of um uh physicians that started uh giving a voice to this issue um came out of Mayo Clinic, and this is what um they published in 2015. You know that you're in an environment that can lead to burnout if you have personally high tolerance to stress. You're tough. You're surgeons. You can withstand long, cold nights, not sleeping for several days, standing in the OR for hours. You can take it. If you think you can take it and you're taking on more and more on yourself, you are at risk of burnout. Your practice is exceptionally chaotic, and I would say from my standpoint being in the ER is very chaotic compared to being in the ICU, for example, because I'm at the street, patients keep coming in. I need to constantly re-triage patients who needs my priority, who and my attention, and who doesn't. So whenever you are in the OR, I would think is a similar stressful environment. This chaotic environment that doesn't give you a chance to take a deep breath, reflect, etc. can increase the risk of burnout. You disagree with your boss, so that doesn't happen here at Boston Children's. We all agree with our bosses and leadership, but that's a factor. You're the emotional buffer. You're the person everyone comes to talk to, and you talk to no one. That's another risk factor. Your job constantly interferes with family events. I would say most physicians, if not all physicians, the thing that we always give up on is something with the family. If I'm needed at work, OK, I'm going to cancel, you know, this event with my husband, for example. For several years, my My husband and I kept talking about having a meeting at least once a month to discuss our family and our jobs and careers. Never happened. Never happened, not even once. And I'll tell you what the solution that I discovered at a later slide. But we tend to cancel things related to the family because we know they love us and they'll understand. But over time, we regret these cancellations and we wish we spent the time with the family. The less autonomy you have, the more likely you will burn out. So less control over your work schedule, your free time, what you do during your clinical time. You don't take care of yourself. I remember as a resident, as a fellow and fellow, like years passed before I did my first dental, you know, check. That's not good. You need to take care of yourself, and going to the dentist or going to your primary physician once a year is like the floor of taking care of yourself. You need to do way more for yourself to be taking care of yourself. So what are these stressors, the drivers of burnout? Paperwork and electronic medical records, when they institute um EPIC at South Shore, one of our satellites, we were asked to do 24 hours of training. Where are these 24 hours coming from? It's from my family time because my clinical schedule is still the same. So, it added to the workload and the load of learning how to use it and then troubleshoot when it goes down, etc. It's a stressor. Feeling undervalued, frustration with referral networks, difficult patients, um, medical or difficult parents, we tend to see that, um, medical legal issues, decreasing autonomy, um, challenging in, um, uh, uh, work-life balance or a better word would be, uh, integration, especially in early career when you have young kids, you want to spend time with them, you miss watching them walk for the first time or talk for the first time. These are frustrating things. Long hours in mid to late career. You've done your due, you've paid your dues, you're now mid to late career. Why are you spending all these hours at work? It can frustrate you and can lead to burnout. Frequent calls, um, again, this is a problem more in mid to late career because somehow we expect an early career to do a lot of calls, be, um, working more nights, etc. Frustration with administrative burdens, and lately and increasingly reimbursement issues. This is my metaphor. So I think of our emotional well-being as a balance. We have stressors in life, no one cruises through easily, and we have our coping skills. Being in the healthcare workforce, we know that we're tough, we're resilient. And we survived long years of education, many call nights, a lot of stresses, and we balanced basically because our coping skills are excellent. We're resilient, no matter what the stresses were. If the balance is good, we're fine. However, when the balance is tips because the stressors keep piling on, we're resilient and now they're adding electronic medical records on us. We're resilient. How about we cut down on physician reimbursement from CMS and otherwise. Um, all of these things over time increases the stressors over the coping skills, and when there is an imbalance, that's what leads to burnout, then depression, then the consequences. This is a metaphor used a lot when people talk about uh burnout in literature, that we have bank accounts, we all have some, some bank accounts. Your physical energy is an account, your emotional energy, your spiritual energy is a bank account. And you have to keep them always full. If you let them drain because you're busy with the stressors, then you become at a higher risk of burnout. So our job is to prevent, um, to prevent, uh, burnout from happening. So, the question is, are we dealing with a new illness, um, or an old one, and now we're better at diagnosing it? Is this a real entity or someone is trying to make a talk or a career or something out of, out of a, a new topic that um is not really a big issue? Anyone has an idea? It's early in the morning, so I'm gonna tell you. So, burnout has been there, has been around, and people have been writing on it for a long time. However, right now, the rate of burning out uh is rising very quickly, um, and um the rate is higher than other professions, so that's why there is increased focus on it. So this is mountain climbing, so people will tell you, when we were in your stage, we went uphill to work, we went uphill to the hospital. This is not about a new generation that can't hack it. This is about a system that is changing, so you still can't climb mountains. What did Mayo Clinic do about it? Mayo Clinic sent a survey to their 7000 physicians basically in their, in their network, and 50% of them had at least one of the 3 symptoms of burnout. The reason why I'm emphasizing that Mayo Clinic, the leader now in the discussion on burnout, had 50% of their physicians with a sign of burnout is because Mayo Clinic is the number one adult hospital in the country repeatedly in US News and World Report. Their physicians are not mediocre, are not the ones that can't hack it. They're really excellent physicians, and despite that, they had a sign of burnout. So again, this is not about character weakness versus strength, people who can hack it and people who can't. There is an an issue basically of concern that is causing more physicians, very qualified physicians, to start having burnout. And the burnout is worsening at a very high rate between 2011 and 2014. Burnout was 45.5% in 2011, went up to 54%. And then people who were happy with their work-life integration were 48%, 48.5%, and it went down to 41%. So we can see in 3 years, things are moving very quickly. In the wrong direction, both in the opposite direction, uh, for the general population, and 50% of the respondents were emotionally exhausted and they found the work less meaningful. This is from an earlier um article in Archive of Internal Medicine, and it shows you that the rate of burnout even for someone like pediatricians and pediatric subspecialties is about 40%. It might be less than the average um uh physicians, and so here is average and here is pediatric subspecialties. 40%, that's more than 1 in 3. That's a lot. That's a lot in any profession. And I think general surgery is the uh where is general surgery? Uh, general surgery is higher than uh pediatrics, I think it's immediately underneath. And here is the difference between 2011 and 2014, and you can tell like in pediatrics, 2011, 35% went up to 46%. So the rate is rising very quickly. Orange are women, um, blue are men. So, um, the rate is rising for both genders, however, especially that now we are in the Me Too era, it's rising for women as well and in women it's been higher. And if you ask why female, female. Physicians is because when I tell my husband to go and pick my daughter from Viola, he will say, OK, fine, I'm going to pick her up today, but does she really need to take viola lessons? So there's always a reason for women to take over something at home in addition to doing All the work that we all do here at work. So, women tend to have high rates of burnout, and that's not good because especially in pediatrics, the number of women applicants for almost every specialty is higher than men. So if we want to keep our workforce healthy, we really need to pay attention to this issue. Why care, harm to healthcare providers, be it nurses, therapists, med students, residents, fellows, and attendings. And the younger you are, the more harmful burnout it is uh for you and the higher is the rate of burnout. So residents burn out faster than fellows, fellows faster than junior faculty. Um, and of course, if you are a senior faculty, the rate of burnout is, um, the lowest. Harm to the families, we're taking care of harm of our, to our families, harm to the profession, harm to the patients, and it impacts the patient's health outcome, it increased the rate of medical errors, which is something we don't want, riskier prescribing practice, lower patient adherence to management plan, and lower patient satisfaction, which is partly what we get reimbursed on right now. So, we do have a problem. We definitely have a problem and I hope I'm uh increasing the awareness of that problem. So, this is not the article that I want you whenever you see it in your uh inbox to ignore. I would like you to start paying attention to, to things uh pertaining to physician well-being and, uh, burnout. And we need to do something different about it. So who should fix it? Um, is it again, the burden completely on the physician, and let's add more stresses, uh, stresses to the physician? The fix should be at a societal level, some of it at an organizational level, but also we need to take care of ourselves at an individual level. The burden is not all on us in this. However, we do have a responsibility for ourselves. At an organizational level, um, training us to become more resilient and targeting these factors that are increasing the stresses on us. So what did Mayo Clinic do, um, in terms of an organizational level? Um, they end up engaging with the physicians basically, and they felt that having us be part of the solution is the way to go, instead of having the solution come from the higher ups down to us. Um, and they felt that the interventions were inexpensive and cost neutral. This gentleman, by the way, you will find his name on a lot of the burnout articles, Tate Shanahan. So he was the leader at Mayo Clinic, and now he got recruited to Stanford and he's leading their physician well-being, uh, program. So Stanford is trying to be a leader, uh, on the matter as well. What they did is that first admitted that it's a problem and assessed it. They surveyed their physicians, they surveyed their healthcare workers, and then they identify physician leaders from each of the departments, each of the groups. They developed interventions, so the administration with the physicians came up with interventions to prevent burnout. And then they encourage peer support. It's such an important thing to encourage peer support, and my understanding is that we're coming full circle on this because institutions used to get concerned about physicians banding together. So a lot of hospitals got rid of physician lounges and stuff like that. And right now with the increased rate of burnout, we're bringing them back because it's such an important thing to have a core group that help each other. Um, they offer incentives, and the incentives were not necessarily expensive expenses. Something like um lunches for a group of physicians once quarterly, once every 3 or 4 months, where you go out, you don't talk about medicine, you just try to relax and unwind in a, in the middle of a very stressful, busy day with so many surgeries, etc. and they found that that was very helpful. Uh, and re-energize them and made them feel that, you know, we're human beings, we're not just cogs and wheel and doing these, uh, these, um, medical practices. Make sure the hospital's culture will achieve its overall mission. So it's not only a mission on paper, it's a mission and cultural change basically. Encourage work-life integration, so daycares on site were helpful, having a gym on site was helpful, um, encouraging people to take time off and spend it with their kids, encouraging people to take their vacations and not incentivize not taking the vacation, so you don't get paid for not taking that time off, um, the opposite. Give healthcare providers resources for self-care, um, and support evidence-based strategies that promote physician engagement. So I told you that I tried to have a meeting with my husband every month, etc. and that never worked, and we have 4 children. We really need to meet and plan our life, and it didn't work. So what I decided to do, and it's something that is evidence-based, once you put your money into an activity, you end up doing it. So I end up purchasing uh Metropolitan Opera season tickets. So, they're expensive, and my husband knows that they're very expensive, so we started going down to New York once a month uh to attend the opera. And once a month, my husband, whether he likes it or not, he's captive to me for 8 hours, 4 hours in each direction, and we're talking, so we talk about the kids we have, the kids we may have in the future, his family, which he doesn't like to talk about, and my family, but This is a sentence on PJ Clark's uh the restaurant just across the street and the only restaurant that's open after the offer is done at 11 something at night, and the owner, uh, Arnold Penner. Uh, had this inscribed on the wall. Every day is a struggle, so we must be kind to one another. Life is tough, and adding more stressors on it makes it tougher. So kindness is such an important thing and you will see in a minute that it's one of the ways we can combat the burnout. Cleveland Clinic. So Mayo we said was the leader, Cleveland Clinic, uh, followed suit, and they end up coming up with a training session, uh, 8-hour training session that has didactic simulation, hands-on stuff, um, um, multiple, uh, chaos of different, um, work-life integration activities, um, and had half of their workforce go through it, so 1500 physicians have been through it already. Um, and they found that people who went through their workshop had higher patient satisfaction scores, the press gaining scores, higher physician empathy scores, self-efficacy, and reduced burnout. What's in it for an organization to do this? It's an, it's an expense, and at the end of the day, it's, it's a business, so what's in it for them? Morally, it's the right thing to do. Ethically, it's the right thing to do, but it feeds into patient satisfaction, which is an important thing, and now it's tied into our reimbursement, lowers errors, which is an important thing in general and for our reimbursement. So again, we're coming to the bottom line. Staff retention, and we all know that to hire someone with your same salary, it costs more than keeping you. So staff retention is such an important thing. And return on investment, basically, the economic cost is, is an important thing. And there's an article that got published in JAMA in 2017, authored by again, this gentleman who was at Mayo. Uh Joel is from, uh, Joel Goh is from Harvard Business School and Christine Sinski is from the American Medical Association, and in it, there's a business model arguing that. Organizations putting programs for, to combat uh burnout basically for physician well-being is not only cost uh neutral, it's cost-effective. So the cost of turnover was an issue, loss of revenue associated with decreased productivity because you're so burned out and exhausted is an issue, and there is the risk and the threat of lower quality of patient care when physicians are burned out, decreased patient satisfaction, and problems with patient safety. I'm sure all the residents have read New England Journal of Medicine of last week, right? All of you, can I quiz you? No, I'm not gonna do it. Remember, I'm a pediatrician, we're nice. So, um, uh, basically, last week, two perspectives came on, uh, burnout. Um, one of them is from, uh, the National Academy of Medicine, which used to be called the Institute of Medicine. And um this is something that came um by email yesterday to every subscriber to New England Journal of Medicine. So now, um, the Mass Medical Society has a CME course on physician well-being. So this is something that's getting national attention and it's becoming a serious issue. The National Academy of Medicine end up designing an action collaborative on clinic clinician well-being and resilience with central goals. So this is now, if I want to take a step away from organizational level, this is the societal level, at a higher level outside of each organization, the Institute of Medicine, um, uh, also known now as the National Academy of Medicine. Decided with 100 organizations signing in on this with them to increase the visibility of uh clinicians' stress and burnout, improve organizations' baseline understanding of it because a lot of organizations think that this is a problem in other hospitals, but in our hospital, everyone is happy. Identify evidence-based solutions and monitor the effectiveness of solutions implementation. So they don't want to just write something and, and leave it there. They want a way to monitor it. They are considering it in par with the issue of patient safety and their report a couple of decades ago to E is Human, which started the whole QY movement and patient safety focus, um, etc. So they're, they're putting the issue of physician well-being and burnout in the same regard basically. They think that because the factors are external, and I want to emphasize repeatedly, especially to people who are similar to my training, like in critical care, surgeons, we tend to think that we're the best, we can hack it, we can tolerate stressors. This is not about you tolerating it. These are external factors that are At risk of breaking you basically. So largely driven external factors that like inefficient work processes, long work hours, heavy workloads, work, uh, home conflicts, and organizations, uh, culture considerations. So the focus will be promoting Solutions at organizational level, systems level, and cultural levels. So this is not a focus on how can we make the physicians stronger. We know you're strong, but the issue is we need to change the systems that keep adding stressors on physicians. Now, this is actually the most important thing that I want to deliver to you today. At an individual level, what can we do? So, we know that society needs to do something about how they view physicians and the stressors they add on physicians, including lower reimbursement. We know that organizations need to help with that as well. However, what is my responsibility to myself? In order to drive the point home, I'm gonna share with you a story, which is a true story. So this is me and my husband, and this is um in a town called Ez. Has anyone been there? No, so, as, oh, you have been excellent, excellent, Sean. I love that. E is the most beautiful place I've ever been to, only maybe second to the Maldives, but beautiful. It's up on the mountain above Villran sur Mer and the Riviera, the French Riviera. So this is the Mediterranean, and this is my husband, and I love him, but he knows he has two competitors, Boston and Maths. So he's very glad that neither one of them is another guy, but I really love Boston. And you would wonder, why do I love Boston? So in 1988, my mother was diagnosed with cancer. We lived in Saudi Arabia. That's where I was born and raised. My father wanted to take her to the best place in the world. Tamoxifen was a new drug. We didn't have it in Saudi Arabia. No matter how much money we were willing to pay, it wasn't available. So we came all the way to Boston to Dana-Farber Cancer Institute just across the street, and my mother was cured. She had stage 3 breast cancer. She had 5 young kids, and we were very concerned about her and thankfully she was cured. In 2012, she had a second cancer and she came to Dana-Farber and a stage 4 metastatic, and again, they did their magic and five years later, she's still doing great. So, Boston for us is like a miracle city. Um, one of the things that I wanted to mention is that my mother had 2 of 3 sisters who had breast cancer and 3 of 6 brothers who had prostate cancer, and we tend to think that these are related, um, illnesses. Back to Boston. So I had 3 training programs here, pediatric, pulmonary, and critical care. I did my MPH here. I had 4 children at the Brigham, delivered by the same obstetrician. It's an awesome city, like, what not to love, and I love clam chowder. But the most important thing, we're the champions, right? Who's excited about Super Bowl this Sunday? Everyone, including my 3 year old. OK. Knowledge is power. So I knew that I'm at risk of breast cancer. What did I do about it? Preemptively, in 1997, um, when I got married, I started going to an oncologist and I visited the oncologist annually. Self-examination, diet, exercise, even as a critical care fellow, I used to wake up in the morning before I go to the hospital and uh play tennis for an hour. Um, early childbearing, which is 28, to my mother, that was very late. Um, and I nursed each child for 2 years. I have an extensive social network. And the only thing is that I would say pediatric critical care fellowship is not necessarily low stress, but aside from that, I did everything right to minimize my risk factors. But I knew that I'm at risk. And I ended up having breast cancer. So 9 years ago, I did have breast cancer. I wasn't disappointed. I wasn't sad. I did not fall on the ground because I knew to expect it. By failing to prepare, you are preparing to fail. And if there's a message that I want to send to you right now, be prepared. Try to prevent burnout from happening to you, but if it happens, know what to do. Instead of saying it's not my problem, it's someone else's problem, I can hack it, etc. You need to seek help if you needed help. During the cancer, I had an early diagnosis, thankfully, because I had the awareness. I summoned all social support, including family, friends. Some of the teachers in this room were also there uh for me um uh at the end of my surgery, um, classmates, teachers, colleagues, neighbors. I had a child psychologist to know how to talk to my kids, family psychologist to know how to talk to my husband. I went to movies, dance, to dinners, lunches, had a beautician, cosmetician, like I had fun with it. I wasn't going to go down easily with this one. I knew what to do, and thankfully, um, it's now history, and I had 2 more children after that. So, what did I do after the diagnosis? I went back to filling up my bucket, back to Boston where things made sense to me because I was in Cincinnati at that time, and I felt that in Boston, things were positive. Let's go back to Boston. And I had 2 more children and hopefully counting if my husband allows me. And that's the bunch, so I have 1611, 7, and 3. I gave a talk about burnout the first time in October, so it's not October, it's 4 months later, but it's always a good time to put a plug for breast cancer awareness. So how can you apply what I did for my breast cancer to the issue of burnout? Individually, before, during, and after. So before burnout, you need to, as much as you can avoid it. How can you avoid it? By filling your buckets, basically, by filling your bank accounts, the emotional bank account, the spiritual bank account, the physical bank account. Sleep is a good thing, and I know that it's a dear thing in surgery, but you need to sleep. You need to eat well. You need to treat yourself well. Be prepared and prophylax yourself. The goal is to stay motivated on the job. And there is a lot of talk now about reframing. So instead of looking at paperwork as this awful thing that we need to do, no, think of paperwork. This is taking care of the patients on papers instead of taking care of the patient in the OR or in the clinic. Remember that professionalism is our contract with the society, and part of professionalism, we talk about upholding ethical principles, how to comport yourself, altruism, all these good things. However, self-preservation and self-care is professionalism. To take care of yourself is part of being professional. That shouldn't be at the end of your priority list. It should be actually high on our priority list. And I always have to bring up professional boundaries because social media is a new thing and it adds to our stresses, so just pay attention to that. One of the ways we can combat burnout is by exercising more humanism, and this is something that my fellowship and a lot of increased awareness about humanism is, is bringing to um to resolving um the issue of uh burnout. So, humanism is the respectful, compassionate relationship between physicians amongst ourselves, um, and with people that we deal with, be it uh in the healthcare team or with the patients. Um, it's the practice of presence, intentionality, uh, attending to the immediacy, being present, basically. You're authentic, you're emotionally available, feeling empathy and expressing compassion. All these things remind you of why you became physicians. Um, you're more engaged, loyal, honest, humble. You share your humanness. It's OK that I shared with you my issue of breast cancer. It doesn't, it doesn't make me cry, actually. It makes me happy that maybe someone will learn to be proactive. And, um, and ready, um, and that will help them. Non abandon abandonment. The benefit of humanism, so it was studied, and programs that promote humanism through mindfulness, emotional intelligence, and self-regulation, the patients are more satisfied. They have more fulfilled relationships with their patients. They reconnect with a, a deeper sense of purpose. Why we're physicians in the first place? Why did we decide to go to surgery in the first place? And they enjoy the practice of medicine more, um, and of course, marked decrease and burnout. So this was from The Lancet 2016. I don't know if any of you have seen this TED Talk, uh, about the happiness Project, uh, the happiness advantage. The things that make us happy, kindness. Being kind to someone, it's like, is there a true altruism, even in, um, uh, philanthropy. I don't think so. I think even when you give, it gives you joy that you have something to give, even if you're kind to your colleague, your superior, your uh janitor in, in the OR. Kindness makes you feel good about yourself. It's a good thing and it makes you happy. Gratitude. We're grateful to be healthy. Because health can be taken at any second. We're grateful to have a job. We're grateful that we're in a safe country. Anytime I pick up the phone to my mom and tell her, can you believe what my husband did now? and I start complaining to her, her immediate response, just be grateful your kids are not drowning in the Mediterranean. Like like, what? How did that even come? Where, where did that come from? But she's right, you know, just open any, any newspaper and you will be grateful for so many things happening even within our country that you are spared these things. So, we, we should be definitely grateful, and that makes you happy. Doesn't mean you don't aspire for better, but while aspiring for the better, don't be too sad you're not there yet. Be happy where you are and aspire for the better. Meditation and mindfulness, there's something called mindfulness-based stress reduction. The idea of meditation is that we have all that noise in our head, demands from home, demands from work, paper you want to publish, grant you want to do. That noise is part of the stress that brings you down on your knees basically with burnout. And meditation and mindfulness, the idea of it is that you shut it down and you start focusing on one thing, your breathing. Think of oxygen molecules. I'm a pulmonologist, so I think of oxygen molecules coming in and out of your lungs, something that shuts everything down, and it needs some practice to shut things down because uh You know, ideas will come into your mind no matter what. But over time, if you practice mindfulness daily, even for 3 minutes, um, there are apps that you can use. You don't need to go into a full workshop or read a whole book about it. There are apps that you can use a timer. All of us now have them on our watches, on our phones for a few minutes, just shut everything down and try to relax. Exercise. And I discovered the best way to exercise is to put it on your calendar as an appointment that you can't cancel, like an appointment with your chief of surgery or an appointment with your chief of anesthesiology. If it's an appointment that you can't cancel, you will do it. And if you pay money for it, more than the money we pay for the gym because clearly it's not motivating us enough, then you will, you will go. Journaling. And journaling starts by finishing your notes, no, I'm joking, but finish your notes because that's a burden off your shoulder. And if you can even write a paragraph a day before you sleep, handwrite it even, because in some ways you're treating yourself to a memory that you will keep and maybe you will revisit or your kids will revisit later on. Write something you're grateful about that day or something that happened that day. Write a paragraph, that also relaxes you. So, very few things, kindness, gratitude, meditation, exercise, and journaling. If you start doing at least one of them every day for a month, and then the second month, add the 2nd 1, and the 2nd month, add the 3rd 1, that's exactly what I did with exercise. After giving birth to my 3rd, I started swimming for 10 minutes, which is 3 songs, listening on them on Neptune. And then I added a song every month, and now I swim 4 times a week for 1 hour each time. And it's basically a number of songs that I'm listening to, the number of songs that I added over the past 3 years. So, you add them on, add them up that way because then it becomes a sustainable habit. Try to take on a lot at the beginning after my talk, you're so enthusiastic, you wanted to treat yourself, and you start signing yourself up to multiple things, you will end up doing nothing. So, have a sustainable habit. You will try your best, but as I did, I tried my best to minimize my risk. But if burnout happen, you now know the signs, the self-doubt, the exhaustion, the feeling of cynicism. If you see any of these signs in you, if you now like take a moment and assess your, your feelings about these issues and you have any of these signs, you need help and you need to get help. There is help here in at Boston Children's. You can call Human Resources or you can go to the office of Uh, staff support, faculty support. There is help at Mass Medical Society. They also have um an office to support physicians. Or you can seek help elsewhere through a therapist, through psychiatrist, through friends, but seek help. You can't just think, I'm tough enough, I'm gonna take it. If you need help, seek help. That's smart. That's not a weakness. And know that you're not alone. Again, remember, 50% of Mayo Clinic physicians had signs of burnout. So, it's not for the weak and it's not you. After you treated yourself from the burnout, back to shoring up your coping skills, filling up your bucket, and prophylax yourself from another round of burnout. So, this map is a map of what is called the Middle East or the Arab world, and I'm from all of it. So, I started, uh, my family started here in the 700s, moved to Morocco, and uh from Morocco to Spain, kicked out, got kicked out of Spain, and in 1835 went back for pilgrimage and then they settled in what's now Israel. And my parents then moved to Syria in 1948, got married and moved to Saudi Arabia, and that's where I was born and raised. And Saudi Arabia had a very big news a couple of months ago. Who knows what it is? We are finally the 168th country, and there are 168 in the world, that is now what, allowing what? Finally, finally, see the big achievement we have. So women now finally can drive. I don't know how she's gonna drive with something covering her face, but they will try to drive. And my husband gets so excited and he told me, so are we ready to go back? It's like, no, it's not gonna happen. There's more that needs to happen before we go back. Um, uh, we should be able to do this before we can go back, car surfing, but because, uh, we were not allowed to drive, of course I'm obsessed with cars, so who knows which car is this? Bye. This is the most expensive car in the world per Forbes 2017. And I can see Doctor Hickey is looking at this like maybe it's his next car, no. So it's $3.9 million. It's, uh, it's, it's not in my horizon or in my future. I'd rather have another child, but um it's Aston Martin. And it's a very expensive car. I told my husband, I'm going to settle for this car and it's much less expensive. It's 1.9 million. Um, so he really needs to work hard to, to please me. Um, and it's called Eriguera. It's a Swedish car. And the reason why I'm showing you a car is like, even if I think of myself as a very expensive car, I need to maintain myself. I need to take care of myself to continue to be such an amazing, amazing car. But at some point, and this is the, the final plug, at some point, the terrain needs to also be fixed because no matter how good you are and how well you maintain yourself, the terrain matters and can wear and tear that car um badly. So, To wrap up, uh, skills and resources we need to do, we have to be professional always. Taking care of yourself is not being nice to yourself, it's your duty as a physician. You really need to take care of yourself. Um, you have to be humanistic always, it's the right thing to do, but it's also helpful to you to combat burnout. Be kind, smile. Ask people about their families, their children. There's no problem, especially in a pediatric hospital, to talk about your kids. Try to bring humanness back to, uh, to the hospital, smile. Mindfulness-based stress reduction, I found it to be very helpful, um, and um there's a lot of research on it, so it's something to consider. Exercise, fitness, sleep, diet, all of these are very important and they're really the floor, so you really need to sleep 6 to 8 hours a day, and you really need to eat good food, not fast food, not while you're running in between ORs, etc. and you have to find at least 3 times a week, 3 days a week to walk half an hour at least to exercise, take care of yourself, because you want to, you want to be functional as a car for the long haul. You don't want only a couple of years of functioning and then not. Build social network and support. Relationships are important in and out of the hospital, so don't put up friendship and relationships until you leave the hospital. Even within the hospital, you don't need to disclose every private information to your new friend at the hospital, but have friendly conversation with them, with your colleagues. And I'll show you something in a second. Pick a specific hobby and build on it, and then 2, and then 3. and the reason why I'm showing you this, this is one of the things that I dragged my poor husband to, so we take tango lessons. Um, and, uh, he, he's OK with it so far. Um, know that there are resources here at Children's if you have any sign of burnout or if you want to learn about more things on work-life integration. Um, and Mass Medical Society has resources, I'm sure, um, Um, the American College of Surgeons, is it called, uh, or anesthesiologists, they have, uh, also resources for you. This is from Harvard Business Review, and Harvard Business Review, once, um, once you have an academic, uh, dispensable, uh, income, um, subscribing to it has been one of the best things I've ever done. So daily I get, um, during the weekdays, I get management tip of the day, and this was on Monday. Don't shy away from making friends at work. And it's such an important thing. They said research shows that people who have friends at work have higher levels of productivity, retention, and job satisfaction. So, it's an important thing to have friendly conversations and make friends at work. Um, it will combat, uh, burnout. It is not you. Again, the final message, this is not you. Uh, it's a systems issue that now organizations, um, uh, Institute of Medicine are addressing as well, but you must start by helping yourself. You can't just put the blame on someone else and wait for the Institute of Medicine to come up with the solutions, the organization to come up with a solution. You need to take care of yourself while these solutions are being implemented. Uh, this is from Newton Public Schools. Take care of yourselves, take care of each other, and, uh, take care of your environment. That's it. Thank you for a wonderful talk, uh, quite different than what we usually have here, and I'm sure that, uh, uh, there'll be many questions. Again, thank you. That was absolutely a great talk. Um, like many institutions, uh, Children's is now starting to focus on this. They've focused, they've organized a hospital, a physician, physician, clinician well-being committee, and they're trying to institute some programs. I'm a co-chair of that committee, and my primary role on that committee is to try to get the institution, Children's Hospital, and its leadership to recognize that one of the major stressors in our lives as clinicians. Is the hospital and the way the hospital uh puts systems into place or doesn't put systems into place, uh, how usable the EMR is, how many surveys they ask us to take, how many forms they ask us to fill out, how many net learnings they ask us to do, uh, so the institutions and the organizations are a major stressor, and very few of those organizations are taking a hard look at what they are asking clinicians to do. Uh, the administrative side of the institutions. Response to regulatory requirements, etc. etc. is simply to transfer that on to clinicians. So what I am trying to get the hospital to do is to get To be mindful of the hospital's substantial contribution to our stress by the way that they put various requirements in place. A good example of the hospital's failure to Uh, reduce the stress on the clinicians is for 10 years we've been trying to get the hospital to increase the number of surgical critical care beds. But what happens every day. We have more OR cases scheduled than we have critical care beds available. So everyone has to either cancel cases or shovel things around. The critical care physicians have to push people out onto the floors. It makes the floor care more stressful, etc. etc. So one of my missions in life going forward is to try to get this hospital to Get the administrative side to understand that they're in their fulfillment of their responsibilities cannot be on the backs of the clinicians, and the institution has a lot of control over the stressors. It has to push back on the regulatory organizations which keep pushing more regulations, more requirements onto clinicians and pulls them away from the things they want to do. So in these talks, I've, I've seen several of them now and very rarely does an institution start to look at itself and its own contribution to the stress and the burnout problem. So I'm here to tell you I'm doing my best to get the institution and its leadership to start looking at that. Any other questions? I have one. Given all of the data that you've shown, are there other data to show that perhaps physicians are spending less time in their careers than they were in the past, that they're actually falling out of the profession? I actually didn't look at that in particular, just that the rate of burnout is increasing, um, but that's an excellent question, if they're changing careers basically. Yeah, I'll look into it. Thank you very much. You're welcome. You're welcome. Have a good day. Right