Dr. Jo Shapiro - We Have Enough Information to Act: Improving Wellbeing by Creating CX of Trust and Respect

Good morning. It's an absolute privilege to introduce our speaker today, Dr. Joe Shapiro, who comes to us from the Brigham and Women's Hospital. Dr. Shapiro has been the chief of the Division of Oto Lerengology there. She's actually one of the first female division chiefs in the Brigham's history. She's speaking to us today from the perspective of her role as the director of the center of peer support and professionalism at the Brigham, and she's really established herself as a leader in understanding wellness, peer support, how we change culture to improve our lifestyles and prevent burnout. And so she's going to speak to us today in that capacity and we're thrilled to have her. Thank you, Dr. Shapiro. Well, it's a complete pleasure to be back here. So in my now, it feels like a pretty long career. I actually, I used to operate here. I used to do Oto Lerengology for adults and children and I took care of the kids here. And then I also want to say that I'm just grateful to all of you for taking care of our children writ large. It's beautiful work you do and it's incredibly challenging and I'm really personally and professionally grateful for that. So thank you. This is a really challenging topic in many ways. We were talking about this earlier because it's a big one and it's really important. So you know, we just have this certain amount of time and I, my goal would be to try to invite you to think about things that we can do moving forward rather than just going over all the data of how bad things are. So that's that's that's where I'd like to leave things. I want to thank the chief residents who invited me really appreciate that. It is, as I say, an honor to be here. I do some consulting work for a group of anesthesiologists who work in patient safety and quality. Can you raise your hand if you can't hear me? Okay, great, fantastic. Okay, so the reason I also want to make a minor correction is after over 35 years at the end of July, I did leave the breakup. That's okay, no worries. It's all good. So I'm working through Mass General and continuing some national international work around this topic, these issues and programs that we're going to talk about today. Yeah, so I mean, I was trained pretty traditionally surgically, you know, a couple years of dental surgery and then I had a neck here. And I was taught a lot of things, but mostly good, but some of the weird things that we were all taught, which were on the good side, everything that happens to the patient is on your shoulders. Like it's your responsibility. Everything is on your shoulders, which I think is great. I mean, we wouldn't want to raise a generation of clinicians that was kind of like, you know, team, whatever, I'm just a cog in the wheel. No, I mean, you want to have that tremendous sense of personal responsibility, but the downside of what we were taught, and this was explicit, was you can't trust anybody. That's literally what we were told. Like you literally cannot trust anybody and those of you in my generation will remember that teaching, which just did not square with most of our experience. Like this clearly, even back in the day, was absolutely a team sport. And so, you know, I was sort of observing this and then moving on to my career. And I was also noticing some other things. And this was especially in my role, some leadership roles, like division chief, and then I was one of the partners, GME directors. I just saw a lot of people suffering. And when I say people, I mean, those of us working doing the actual work, whether it was a clinical care, education research, but particularly clinical care in some ways. And I didn't really necessarily see ourselves as identifying the fact that we were working within organizations, and that organizations themselves actually have a huge impact on the work that we do. And that, again, was part of the culture and the training, which is you're an individual and, you know, not really identifying as part of like an organization. But it became apparent to me, and this is nothing original, because it's very, very clear, for example, in patient safety research, that the culture of an organization actually is a huge driver of the outcomes of the work that we do, the things that we actually care about. And this is a quote from Parker Palmer, who's an activist and educator, that institutions are where the human heart gets either welcomed or thwarted or broken. And the more I became a leader and the more I did clinical practice, the more I realized that it was our responsibility in an organization to actually welcome the human heart, and we weren't really doing that. And I'm going to be pretty explicit about ways. I don't think we were doing that, and what that's led to. Meanwhile, nationally, there started to be this awareness of like actually maybe the experience that we have as people working in these organizations matters. You know, maybe actually it matters, and there's more and more evidence that it matters deeply what our experience is and how we're doing. So you probably know there is an epidemic of burnout. And I think the first two bullet points are the ones that I think are being most well correlated with again, the research that's used in terms of measuring this. But it's really this depersonalization and a sense of emotional exhaustion. And it's a it's a it's not a mental illness. It's an occupational problem. And burnout is pretty prevalent, unfortunately. And this you don't have to read it except to know that there's just no specialty that is sequestered or free from risk of becoming burnt out. And the other thing to know about burnout is it's not like either you're going to have it or you're not in your career where all at risk are different parts of our careers for being burnt out. The thing is if you're burnt out, there's all sorts of other things that go along with that. But from the patient's point of view, you don't want to be cared for by a burnt out physician. We just do bad work. We really do. Obviously unintentionally. Institutionally, it's tremendously costly to have burnout. Okay. Huge. And if you haven't seen this, I put it in almost every talk that I do because I think it's just we have to look this square in the eye. We're not comparing one side to the other. But just if you look at the rate of suicide if you're a male physician is 40% higher than if you're male in the US. The rate of suicide if your female physician is 130% higher than women in the US. Every single day plus a physician in the US dies by suicide. Every single day. Okay. This is totally horrible. And it is something that we can do something about. We absolutely can. It's not going to be easy problem to fix, but it is absolutely something that we can fix. So what I'm talking about is actually a huge changing culture. Because of these reasons that are culture in many ways has been wonderful in many ways, but also in these ways not okay and has led to burnout and then all the other consequences from that. So if culture we know culture drives outcomes again look at the patient safety literature, psychological safety of an organization that means not for patients, psychological safety for the people who work in the organization is correlated with safer patient care. So that's a cultural thing that you can measure is their psychological safety in an organization and that actually is correlated with patient care. We know that culture absolutely drives outcomes, but has any of you ever worked in an organization or heard of an organization where there was like a manual of culture like you could look it up. Oh, that's how we do it in this division or you know what children's are cultures this or over here we do it this way. No, it's never written down. And yet I'm you know I'm arguing that and the data supports it. It's incredibly powerful driver. So what the heck is it right? It's not even written down. It's not in a policy. It's not an emission statement. It's not in rules. It's not in medical staff bylaws. It's but it's so powerful. So this is one definition. I really like it's a from a colleague of mine. It's patterns of relating that persist and change through ongoing interaction. So this is what I told you I was going to convince you of and that is we can change the culture literally today. We don't have to take a vote. We don't have to get you know total consensus in the areas that we control right and I if you're a student here or you're a you know a junior resident you probably don't feel like you have any control over any parts of your life. But you have some right. For example, if you're resident you have immense control over how students are treated just as an example. Okay huge control over that. And if you're a leader you have a lot of control and responsibility around this and we don't have to make any major changes. We don't even have to spend any money on this. We can decide we can start to look at what are what am I doing personally and what are we doing as an organization or a team or a department or a division every day that supports the culture that we want and that what are we doing that doesn't that undermines trust that makes people feel not fine about walking into work. And so that's the beauty of this is these are real changes we can make. I'm going to suggest much more big programmatic organizational changes. That's my experience but I want you to leave with even if your organization decides not to do any of these or doesn't think this is the right way to go. You can we can any of us can say we're going to support a culture at least in the areas that we have some control over. And this is from a actually a person who writes about organizational change is this idea that you know if they used to be built on force and now they're actually built on trust and that's our responsibility. So let me just talk about the one definition of a very important term that I already used which is this idea of psychological safety. You know it when you've had it and we've all had it. If you ever worked really hard you had a very very challenging clinical day and everybody on the team feels like you're supported by them and you're supporting them and at the center of that is the patient essentially figuratively. It feels so good you can rely on each other. You know you have each other's back. It's a beautiful feeling we've all had it. That's what we're going for. And so Amy Edmonton writes a lot about psychological safety because she is a researcher at Harvard and she's found that it correlates very much with some important outcomes but just to define it here it's a shared belief in interpersonal safety within the team and it's the sense of confidence is to quote from her that the team will not embarrass reject or punish someone for speaking up. Okay it seems pretty basic doesn't it but we all know that is not always the case in teams especially in you know highly competitive and very very fast-paced organizations this is not always the case. It stems from mutual respect and trust among the team members. One of the things that I struggled with when I was first trying to get the professionals and work kind of going forward and really bring on the I would say the senior people that I work with was the people in my level of seniority were very concerned about the fact that we were the perception was we were trying to say we shouldn't have hierarchy in medicine and let me be clear about that. I love hierarchy especially now at the top such a fan it's wonderful okay there's nothing wrong with hierarchy right I mean lots of very very good complicated organizations depend on hierarchy which is a lot about role clarity and who's got responsibility for what but we are talking here about a hierarchy of responsibility not a hierarchy of respect so if your job is to sweep out the operating room right you deserve as much respect as I do being in charge of that team and now I have more responsibility and very specific responsibilities that maybe override other people's responsibilities but not respect and that's I think where we have the people to say that we can treat each other respectfully and still maintain our sense of responsibility autonomy and all those things that especially as surgeons really value okay so let's just move this why is that not doing I put this up just to remind myself to say I very respectful of culture whether it's different countries or you know of language of specialty of gender of all sorts of stuff right but what's so surprising to me and I had the wonderful experience of going to multiple dozens and dozens and dozens of different healthcare organizations across our country and other countries as well and what's so striking to me is the similarity across all of those other different micro cultures of the medical culture the culture of medicine so when I talk about culture and medicine I'm talking about all of us right it includes children's hospital and it includes you know Stanford and it includes private practice and it's really it's very consistent across cultures even though of course there's some you know some differences always so I put this up because those of us thinking about how are we going to address well-being how are we going to support well-being and decrease burnout there by the way what you do to decrease burnout is not always exactly the same as what you do to improve well-being I just want to make that point obviously you know we want to do both but this was a original way of some some really wonderful colleagues of kind of thinking about this I think most of us are thinking this is a little bit simplistic and separate but it's a good way to just start the conversation and it it lets me talk about I have too many rants and I'm going to do them right now and I get them over with in the beginning when we were talking about wellness does anybody have this like association with people saying you should do yoga and eat you know good food right so the problem with that is like please don't go out and say Joe Shapiro doesn't believe in you know good nutrition and exercise because I do but the thing is there's two problems with focusing solely on personal resilience one is if you say to me you know or a group let's say let's pick residents and you go you really should be exercising and you should be eating well etc etc but in your work day you are not given any opportunity or any means to actually do those things to do anything oh you should really get good mental health care oh like when am I supposed to get good mental health care when am I supposed to see my internist you know you you're not providing me with that opportunity so one is like we say that it's important but then we don't actually give people the chance to do it right so there's that and the other thing is at some point if you ask people to deep breathe through a toxic system that's not okay that's just not okay so it put it the problem with personal resilience isn't that it's not important it's that it's it's just a part of this a lot of this has to do with these other domains I'm the efficiency of practice is clearly that's what most of us now think of when we think of what's causing burnout what do you think most people say the HR EHR right now we know in many ways like the HR isn't actually like it's a very that's a very technical way of looking at it like this thing is now making me miserable but it's not really the HR it's how the EHR is used who's who's being asked to spend most time with it how it is you how whether it's actually serving us in patient care or serving people who are doing billing though it's the use of the HR that's the problem but the point I want to say about the efficiency of practices there are a lot of good people who are working on this and it's so important and I'm sure you have I'm hopeful you have groups we're thinking about what's your work day like are you actually doing work that you know we're all going to be doing some work we don't want to do but is a lot of it does does some of it have meaning for you is it really the work that you're meant to do if you will and so that's really important but what I want to say my second rant is at some point if you ask people to see too many patients if you're pushing too hard for throughput productivity pressures what it's called I don't care what else you do people are going to burn out they just are we can't keep up with it it's not safe care it's not good for us it causes all sorts of imbalance in work life and and it's just not it's just a terrible way to take care of people when you're seeing too many people so I just want to say like at some point you can't balance the the issue of access and productivity solely on the backs of physicians and I you know I'm not the first person to say this but I do want to say like that's I think we have to stand up at some point you know and say this is not okay but we yeah we we have to we have to be more in balance the the culture of wellness is I think it's not a separate piece of the pie I think the idea of culture is permeates everything but it's a nice idea that they put this as something that we should be thinking about so the the programs I'm going to talk about specifically around addressing proving well-being are really around here okay sort of a combination of both one thing that has been shown is that organizational approaches to well-being tend to be more effective that means stop telling you know having yoga classes or telling people I mean telling people to eat better please eat better but that's not going to solve the problem okay so on the dark side this is so a look at this on the dark side this is a study I just put up a couple studies here 300 surgical cases where there was less teamwork the the the patients were at higher risk for death and complications all right so we know the teamwork right when it goes wrong is really bad for patient care on the bright side when there was positive communication collaboration between attending and residents patients had lower risk adjusted morbidity so I put these up just because I want you to see that the that the the beauty I think in most cases is if we do things that promote well-being for for physicians and other health care team members they are which teamwork does by the way they're going to have a positive effect on the outcomes for our patients and that's fantastic it is those two things are not in opposition the well-being of us and the well-being is the truly of our patients we take care of this is a study looking at how respect makes us feel and and and its relationship to satisfaction in our jobs and burnout and this was a study looking at you know look thousands of physicians and asking them to say you know how does your supervising physician treat you essentially in other words are you treated with respect and these were the domains about respect and look at this like this is a a driver of outcomes that we now need to be caring about burnout well-being job satisfaction all those things this is a study that actually looked at teamwork measuring teamwork and its correlation with patient outcomes and again just to summarize this study and this was teamwork amongst an entire health care team this was specifically who did knee replacements in this were nine different hospitals across the US and those teams that functioned better actually got better outcomes for patients so imagine that these are things that we think of as very upstream like how we're working together as a team affecting something that we all care desperately about which is our patients their outcomes now to be fair to my generation we didn't know this we didn't know it nobody talked about teamwork nobody talked about interpersonal respect treating people professionalism it didn't matter because we did we didn't think it mattered I should say where's it mattered but we just didn't know so we focus solely on cognitive and technical skills right and prowess and that's what we thought mattered in terms of patient care we neglected all these other domains which is how we treated each other and even how we treated ourselves and you know actually my goal is that that same compassion and grace and caring that we give to our patients we give to ourselves and each other that's the goal really for two reasons one is it here's the day to showing it's going to give better patient care but also we matter too I mean the irony of being in a healing profession and not helping heal each other and ourselves is just it's unbelievable so I'm going to talk about a specific program just take a read of this no matter who you are and how smart you are and how well trained you are you're all going to have to face this we all have and we will it's we we're human we're wired to make errors errors will happen I'm not saying they should harm patients we should be going to zero harm but it will never be through zero error you know that right humans are wired to make errors you cannot eliminate errors from any enterprise ever you can't you can decrease the chance that they occur and you can certainly try to set up a system where they don't reach the patient but you you can't have none of these so we're going to have to face this to me every single organization should have a peer support program every single one because if we're not there as I say for each other at these times are most vulnerable times I just think the rest is like just kind of window dressing not bad to do but let's be there for each other so let me talk about why these are some of the emotions that many many clinicians feel after being involved in an error and especially this sense of shame and shame is where you feel terrible about something you're taking personal responsibility and you feel it's because you are not worthy you're not a good enough physician nurse what have you it's it it has it's you feel it's a reflection of who you are not just this not just but the fact that this happened and you feel bad about it but it's a reflection of who you are very negative and at least people just have a sense of I wonder if I should keep doing this am I good enough I'd I really need to rethink this one of the there was a study done by Helmrish and just because I was always puzzled like why do we feel so ashamed after medical errors you know understanding that we're human we make errors and we should be understanding systems and how these things work and the study by Helmrish just talking about this the similarity in inculturation between in aviation and medicine really really I thought was as his worth this quote that both stress the need for perfection and a deep perception of personal invulnerability so if we're taught that the way to keep our patients safe is for us to be perfect to have absolutely no errors when they do happen when we when we do make a mistake we are going to feel horrible because we've been told that we're supposed to be perfect and I just again I have really bad news perfection is not even on the table as a possibility and also by the way did you know that that the the profession of medicine selects for perfectionists so most of us have a bit of a streak of that and now you put up I've made an error I'm supposed to be perfect I was taught I was supposed to be perfect whether implicitly or explicitly and now I can see that I'm clearly not what do I do with that also I think physicians in particular we are I mean we're really taught like you're supposed to put your head down get your work done don't complain right and this shouldn't hurt you that none of these things you see a patient die even though you know I mean it would be traumatic for a non-clinician but we're it's not supposed to bother us because we are tough and it's we signed up for this and there's no crying in surgery right well the fact is we're human right we're human of course these things affect us would you do you even want to be do you want a colleague you want someone taking care of you doesn't have any emotions now I don't mean like in the middle of a code you know or the blood spurting in your operation and you're like oh my god this is so stressful and no like you know get your emotional the emotional impact of things I'm not talking about acutely we do have to train ourselves not to be you know involved in those emotions essentially or control our rouse the level etc but I'm talking about over time like what about when you walk out of the OR what about after clinic what about that you know and we do know and I'll show you there's some long-term potential consequences of not dealing with this I think a lot of us are afraid what are we afraid of we first you first find out you made a medical error just anybody shout out you know people are afraid what are we afraid of I mean rational fear yep that you know the patient is gonna what sorry what are we afraid of after we've just learned that there's we've made a medical error patient might be harmed we're afraid certainly the patient having you know it causing worse bad problems what else what about for ourselves what are we afraid of yeah we're afraid we're gonna get sued that is by the way an extremely realistic fear right okay what else are we afraid of disappointment yep in ourselves and our reputation people are very afraid of reputation and I want to want to speak to that for a second did you did children's the safety people did did you all get the memo that you're done with shame and blame right we're not okay we say we are we do we'd have a just culture right that's what we have a safety culture here you can't just take a culture that we have been absolutely living and breathing forever and say we're done with that we're now we we've moved on because shame and blame is still with us okay now shame and blame the problem is shame and blame what is the problem with it like if it were good I would be I have to be a fan of it but why is it bad why why are we saying we have to go to a just culture a safety culture why do we have to have psychological safety why are we trying to move away from shame and blame because shame and blame doesn't really address the problems thank you it doesn't right so it that it completely ignore systems issues I mean shame and blame you don't use I mean shame and blame is pretty much an individual game right it's who did what wrong and let's make sure they know it and they they they they can try it about it all right so it doesn't dress systems issues and the other thing it does is it drives people underground I don't know if you know this but again data to back this up is we under report our errors residents actually under report making errors to the attendings like literally hiding things from attendings we as a as a collective group we don't there if we could go unnoticed for having made an error we do often do and it's because we're terrified right so the shame and blame actually because it causes decrease reporting of errors it actually robs us of the opportunity to learn from our errors all of us collectively individually personally and system wide and so shame and blame is actually worse than neutral it really drives it it it it minimizes the chance to actually bake make the the system safer so just read this I don't know if you've seen this study now the reason I put this up here a lot of people use this to talk about gender you know uncon this is unconscious bias obviously I mean there's no but none of the people referring or not referring or going like oh her patient died so I'm going to refer like no this is unconscious bias I put it here because this is an example of unconscious but clear punishment specifically directed to women surgeons differentially for men but it's just an example of guess what the reason we're afraid of our reputation is because we do judge each other so all these things oh and by the way you know do you think the litigation system is focused on making the system safer no it's focused on punishment so we are still we're still there right now there's a way forward from shame and blame but we have to recognize when our M&M is still doing shame and blame when our root cause analysis is still doing it with a lens with a lens of shame and blame when we're unable to make systems changes that really need to be put in place or my colleagues going to make the same error I did because it was a reasonable thing at the moment to think about there are so many and some of these are from other countries that I just show you that that there are systems out there structural systems that are supporting shame and blame that we have to start to look at and correct okay we do it doesn't mean we shouldn't get our act together in the house of medicine and say look even though the litigation system is bad and horrible at least we're going to take care of each other but all these things can be extremely punishing media how about that people get tried in the media in a shame and blame way there's no discussion of systems it's it's about punishment so these are realistic fears and these all can lead us to a sense of being alone it feels very lonely and by the way being isolated is very very stressful for humans because we're extremely social and it causes acute and chronic stress this is there's a fair amount I should say pretty a lot of studies on the impact of errors this one is on physician the impact on physicians and you can see that even with near misses that 51% had what didn't even reach the patient right increased anxiety about future errors decreased job confidence so you know it this is these are a lot of people who are suffering if you so just look at the bottom of this this burnout and depression are independent predictors of reporting of having made a recent medical error so this is the impact of errors on us this is now this isn't like you know 50 years ago and the the literature is pretty convincing that if you've made an error you have a higher chance of becoming burned out if you are burned out you have a higher chance of making a medical error I mean it makes sense right that that would be the case but let's do something to interrupt this cycle very very specifically if you've made a medical error your chance of having suicidal ideation increases so error is a risk factor for for physician suicide it's not the only factor but it is a risk factor so I'm just saying today let's do something about this this is leaving this untreated right it's it's not acceptable it just isn't so our thought was what are we going to do about this we know we have the data we we actually did some of the research in it what are we going to do about it we decide it we're going to do peer support and the reason we decided we're going to do peer support was many reasons but one of them was a study that that we published that this part of the study this particular graph shows the answer to the question of the physicians we survey if you were involved in a medical error where would you most like to get support from and you know 88% wanted it from a physician colleague even though we have great employees this instance program mental health practitioner people want to talk to a colleague because a really colleagues know what it feels like so peers that's what people need this was another study that looked at what helps this was also around physicians in particular what helps physicians if they've made a medical error learn grow and get through it in a way that caught that leads to growth and and resilience actually which is recovery and growth after trauma and talking about it with a colleague was one of the one of the positive factors associated with resilience after error so peer support there's a fair amount of triggers that I think should generate peer support one would be an adverse event whether there's an error or not but if it's you know due to our care that's particularly upsetting communication coaching how do we talk to patients after errors that's very dicey very difficult we shouldn't leave each other alone to do that being reported to the board of registration being named in a lawsuit automatic automatic should have peer support chronic stress people you know just really feeling awful they should have access to peer support patient aggression pretty upsetting when patients families or patients themselves or behave physically or verbally aggressively towards us just some of the stuff we do caring for trauma victims global crisis relief these are just human things on the human scale that would be could be emotionally stressful for people so before I go off of that what I want to say is that peer support programs are not that hard to set up but what we found I've helped 50 different programs across the country get set up what we found was you you can't do them as a as a you have to do them as a reach out so we trained like 50 different specialties different physicians and actually we did a for advanced practice providers and nurses as well but anyway we had all these people ready I trained them peer support already guess how many peers our colleagues reached out and said I need help can you help me 0 right 0 and that's you know it makes sense I have some more data showing you that there's lots of barriers to doing that but one of them is look first of all I feel stupid if it's about an error I feel really dumb that I did this in a shamed and then I feel worse that it's actually bothering me because I'm supposed to take it and I see no I don't see anybody else saying they feel terrible after errors because we're all suffering in silence so I think the ideal program is basically one that is a reach out which is that when we hear about any kind of emotionally stressful event it could be something that was reported to a risk management or patient safety it could be something that one of the clinical leaders hears about it could be any one of those triggers that whoever's leading the peer support program assigns a trained peer supporter to reach out to the colleague and say hey listen I don't know if you know this but we have a peer support program and we reach out to anybody involved in a whatever event and the reason we do is because I and every other colleague I know has been involved in an event like this and sometimes it helps to talk to a colleague would you like to do that I'd be happy to do that with you okay it's not saying I'm calling you because I know you're a big loser and you're going to fall apart right it's saying of course I'm calling you but that's what we do of course we would check on you that's what we do everybody gets a call when there's one of these triggers okay so that's a peer support program I think it to be to really work in a psychologically safe environment the way the environment the way the organization analyzes events right that have when things have gone wrong has a huge impact on how we feel about our work so we saw in this study that one of the positive factors for actually resilience after errors is having an opportunity to learn about what happened taking some personal responsibility and systems but it's not either right it's like what now I know that I did this wrong here's what I understand about it I'd like to help alert my colleagues to that has anybody has any one of you in this room ever been in an M&M where you you've made an error and your colleagues are incredibly helpful about like hey that happened to me here's I think maybe what what I've done since then is this you know this suture or this approach or this incision or what have you I mean I'm this I guess I make it rhetorical but I can tell you I have as the person who's made the error it is so supportive to have your colleagues help you in a respectful way learn from their experience and you learn from yours and then you're all teaching each other and then if there's a systems issue that comes up getting somebody to be able to make the change in the system because someone's going to make the same error again okay so I'm telling you these moments if we could make sure that every single one of us has an opportunity whether it's monthly I mean I think it should be at least monthly where we're sitting down and going over things that didn't go well and then taking those events and analyzing them with a certain framework that I'm going to share with you I think based on some study that we did this is my proposal for how we do an event analysis whether it's an M&M root cause collaborative case review doesn't matter quality improvement you know group what have you is to sit down and say we're not here to shame and blame but we're here to answer the following questions knowing what we know now looking at this event are there things we would do differently going forward that doesn't mean we messed up it means we just want to learn are there something to learn from great if not okay let's move on to the next case also what what went well because I bet you 100% that if you take an event that had a bad outcome there were series of things that probably went wrong but there were series of things that also you'd want that we're good right so you want to learn from both of those and then of those things where we've learned did were any of these an actual error an errors are defined as failure of an intended plan to be carried out as intended or picking the wrong plan right that's what an error is okay it's not a statement of you know your integrity and then and this is a legal question actually it is not to be asked in M&M but is any of those things that we did actually unreasonable outside of the standard of care because then that's just you know we still need to do all the learning up there right but then we do some other things which I'll mention briefly so this is what we're going for we're going for a culture of safety because a culture of safety psychological safety for us improves our well-being right our sense of I can do this and I can and I can learn from my errors and I also take personal responsibility for doing everything I can to be well-rested and well-taught and get help when I need it and the system will support me in setting it up that way right and then we'll help learn from the errors and fix as as I say here this is from Alan Franklin my glenars work find and fix vulnerabilities in our systems and behaviors I put this up as some just about done but I put this up because when I first started doing peer support and you know talk now like we've got to do this and just getting it organized some people said to me Joe that's such a great idea but why are you bothering because the whole litigation system is based on shame and blame so how can you even do this you know in the setting of having such a litigious blaming kind of society and my answer at that time is a little different it's part of its stance which is that is a terrible system I hate it it's horrible and we know it's horrible there's a great study by Troy Brennan and colleagues that looked at how horrible the litigation system is because it actually most of the cases they analyze thousands of cases actually from New York looking at records New York State and what they found is that most cases that go into the court system are not actual cases of negligence outside of the standard of care so you're you're putting health care providers particularly physicians through a horrific experience and then the patients aren't you know the people who are suing you are not the really the ones deserving of any kind of financial recompense on the other hand what they found was looking through the charts there were multiple cases of negligence that didn't go to the courts so the very people who should be getting financial compensation right are not and meanwhile were dragged through the whole system it's crazy so my answer to that was it's a bad system but let's get our house of medicine in order like at least we won't be blaming each other and you know you know all those things that I said we do now I can say and this my optimistic side I think in 10 years we won't have this litigation system anymore and I don't know if you know this and I don't know I'm sorry I should know but not sure how involved children's is in this but many of the hospitals in in in Boston are are moving towards these communication resolution programs they're called care programs are different but the idea is we ask those questions as event analysis and if the last question is and it's very rarely true but if the answer is yes that we really if this was this was what we would consider as an organization's substandard care doesn't mean the person providing the care the one at the sharp end of the error was substandard person but the care we gave the outcome that happened it's just no it's not it's not okay then we will have a negotiation this is all through cry co of course with the the family the patient would have you about financial restitution it's restitution it's not really resolution it's restitution as an offer and it there's a lot there've been these programs have been well studied they turn out to this is not why to do them the reason to do them is the right thing to do but they turn out to actually save money they're people were terrified and we go we're gonna offer money now let's leave it that they have to sue the heck out of us to get the money it's just wrong so these programs save money and guess what else they save they save us because we don't have to go through this litigation system we still should learn and get better and all those things I mean that's part of the event analysis so I think I really feel optimistic because I and and there's a disclosure is it's not a financial one but I do I'm on the the the group that nationally is trying to help organizations actually develop these programs so my concluding push is to say that I think you need you need programs actual programs that will push the culture in the right direction and this is how I see peer support for example and professionalism and respect programs where we say you know how we interact with each other matters that they'll promote trust and particularly around peer support programs is we're gonna help go from shame and blame to just culture get away from this idea that for me that that I'm supposed to be personally invulnerable that is I never should make a mistake perfectionism it's totally unrealistic to the idea that yes I'm human I make mistakes I still feel bad about it and by the way we should feel bad I'm not saying those reactions like we should we again do you want to raise raise a generation of clinicians that goes like I don't care it wasn't my fault no we should feel bad but you don't want to feel permanently bad and you don't want to feel so bad that you become burned out you certainly don't want to feel so bad that you die by suicide right okay so it's coping with and getting through the emotions with support so it goes away from expecting that none of this should hurt to you know I'm human so sometimes these things they do get to you and and I'd like some help with that that would be amazing right going from your alone you feel totally alone because the first thing you're taught is don't told don't talk to anybody and peer support is a way of saying that's generally true like you shouldn't just start talking about it with people at home or colleagues even if it's not in a protected environment peer support is a way of talking about it in a very discrete way if you will and the ideas you're not alone right the reason I'm reaching out is appear supporters because I and all my colleagues have been through something like this would you like to talk about it and then I think a big one is and I think this is changing but I was we my generation absolutely raised on the self-care is selfish no question about it time off for anything personal I mean I actually have a memory of having a fever I was probably 104 or something and I was vomiting like mad and I said to my chief resident I got to leave clinic and she basically said they don't make them like they used to and I felt guilty like I felt bad about leaving that's ridiculous I mean first of all if you were you don't want me near the patient but okay but this idea of self-care selfish again you there's no memo that's going to go out and saying like oh we don't believe that anymore there's still vestiges of that so I think what we have and look I'm not talking about as I said you know in the middle of I mean listen you know we're not talking about working two hours a day and then going and having massage though that'd be really nice we're still working really hard we're still putting patients first right all of these things and at some point with however we can we do need to take care of ourselves we have to because it shows it you know it helps us show up with compassion for our patients but also we want to sustain our careers I want you to sustain your careers what a loss to society if people drop out of medicine that's awful right and I am in no way suggesting I've got the answers we've nailed this you know every organization that I've been to and in communication with and have friends at that we're all trying to figure out what are the best way forward I just this is these are programs that I'm very familiar with and we started them with the idea of well-being there's many more I think that are important and good to do and I think as an organization what you know what you want to do is think about what are you doing how are you supporting those each other and yourself how is that happening here and then find ways to do more of it the good stuff right and if there's things that are undermining people's well-being that are known undermining factors like disrespect right they got to go away you got it we got to stop it it's not okay I just leave you before I my very last slide the ACGME convened the first this like four years ago the first national conference it was a small group it was like 150 of us on physician well-being and they had people for you know lots of different people and and I was I was really honored to be there and it was very moving because Tom Naska who's head of the ACGME stood up and he basically say that I'm doing this because I really care and I want you to all hear a story and the family of Greg Feldman stood up and told the story of Greg Feldman who was a Harvard med student and then he was Stanford General Surgery resident did beautifully he actually was an amazing student he gave the valedictorian address at Harvard med school graduation he went on to Stanford did beautifully he was doing global health work lots of things and then he went to do a fellowship somewhere in the Midwest and he basically came essentially in the crosshairs of a really really horrible unprofessional attending who just targeted him around humiliation bullied him and Greg died by suicide he had no known mental health problems right and his family you know believe in and friends and I've actually to us because some of his friends are working the Harvard med school community believe that that bullying was a major factor so you know Tom put this like front and center of this meeting to think about like how are we going to change how are we going to improve well being any wanted Greg's story to be told and I have permission of Greg's mom who I got to meet and I'm still in contact with to you know to rip the story but the these are high stakes right and the stuff that we need to do is not neurosurgery or general pediatric surgery it's not that hard it isn't you know I can tell you it isn't it's totally doable and and what I said in the beginning which is the fact that we all come into this as truly caring incredibly dedicated hardworking compassionate people that's the energy we need to harness right by taking care of each other by making sure the organization is helping take care of us treating us respectfully when decisions are made made with us not about us that's that's what we can do and I'm completely optimistic and you know I think there's some data to show things are getting better it's very hard to show an individual program is having a you know decreasing the suicide rate I mean that's never going to be proven but I think there's some indirect evidence that these kind of well-being programs are helpful I don't think they're all going to be helpful but I think many of them will be so my final slide is so I went to I was doing some work in Australia with programmatic development and my husband actually came with me we'd never been to Australia before and so we after I did my work we went to Sydney so what did we have to do as tourists when you're in Sydney all right we had to go to the Opera House so we went to the Opera House and there was a big construction project around like the a plaza you know the steps of the Opera House and these were that this was posted for the construction crew so I'm going to read it our house rules I will do everything I can to go home safe never forget rule number one respect my workmates communicate positively with those around me challenge my mates to do the right thing present fit for duty and ready to do my best never take shortcuts at the expense of safety lead by example and be proud of my work speak up if I see something not quite right step up and help my workmates if I see they need help and I was like that's us that's us that's who we are so thank you I'm completely thrilled to be back here and I'm really happy and and encourage that you all showed up and care about this because I think it's I think it matters really really deeply so thank you absolutely would invite questions and even if it's it doesn't even have to be questions maybe I'll ask you a question any one of you where does this land for you like what do you feel now what are you thinking like that's ridiculous or we can't do that or I we do that already or that's a good idea this one not so much what where how how was this landed with you thank you and I think that is really well said they're probably mapped on the same chromosome you know that kind of and a lot of this does I was going to say depend on but I think it's related to as you say to emotional intelligence and the part of a no emotional intelligence that that that looks at you know emotional self-regulation awareness of what am I feeling right because peer support actually when the peer support interventions are about helping people process what they feel and and starting to get in touch with that even if it hurts like I feel you know incompetent those sorts of things the child what's interesting is the challenges the reason I recommend training peer supporters is because peers like if if I'm going to support you right there's a good chance especially if I'm a surgeon if you tell me you're feeling horrible about something I'm going to say well hey that wasn't so bad what you did I mean they were going to do badly anyway so you know I think you know you really shouldn't feel bad that's my discomfort I don't I want to it's also my obsession as a surgeon with I want to fix your pain and I think to your pointer these are psychic they're emotional injuries if you will and they're not fixable in the same way and I think that's why we avoid that because we're really uncomfortable with that but this idea of there are ways of helping people through including your patients through emotionally traumatic things right the don't show in you know ways that you it's not about fixing it it's more about acknowledging validating listening sharing where it's relevant those sorts of things so I think that's really a really wonderful point thank you anything else that hit anybody in a certain way thank you we're gonna and would you just say your name so everybody gets to know you because you this is a future and current superstar right here amazing so my name is Archina Pouduri I'm in the HST program I'm a first-year student so I've probably spent more time being a patient than interacting with patients from the physician side one thing that struck me is that from day one of our training it's emphasized that patients come above everything else so I was told that even if you're sick or dying you cannot miss clinic and I can understand that because patients are the most important thing in this profession there's a lot of unwillingness to change something that we're used to if we don't have evidence very strong evidence that it will not compromise patient care and so if we even have any intuition that self-care will make us worse physicians we will not make that change and there's also a lot of tension in terms of individuality and what the role of being an individual as a physician is so in one of my ethics classes we had a case where a patient called told a resident a person of color to go back to their country and the resident was not sure how to deal with that and didn't really get much support from other residents or physicians and so I think there are small steps that we're making to address that but it's always very very moderated and careful because we don't want to compromise patient care so what everything you said spoke to me a lot and I think peer support is a really tangible way to address that. Well thank you and also thanks for bringing up this issue I mean of course you know in this hour I did have time to address everything but you know one of the things there's a lot of data which if anyone's interested at any time I'm happy to talk about it or help people with it in any way that we have ongoing harassment and discrimination I mean shocking right it's not shocking we know this there there was a national academy of medicine studies showing especially for students and residents in medicine it's it's rampant and the effect it has on them it's just unbelievably negative I should say us but okay so what do we do about that well one of the things that we should be doing is we should be teaching the healthcare team how to handle microaggressions right what do you do when your patient says something like that to somebody because in answer to that is I mean and I do some of this training at different hospitals is you have to train people how to and essentially what we really have to train are upstanders not leave the responsibility on the person who was discriminated against her harassed to fend for herself or himself but to get the people who are in power if possible but you know people around the bystanders to be able to say I you know that was problematic or even if it's not in front of the patient doing it separately in front of the rest of the team so this is the kind of sensibility and sensitivity that we have to start to develop because these things are they feel they may feel small right these little off-hand things here or they are disrespect harassment discriminator whatever they are they have this huge negative impact on the workforce and but also on us as you know as individuals and so you know thank you for bringing up that example because by the way I'm going to say this loud and clear and I can I have to say this because I feel like I have to neutralize what I'm going to say is I was a short center finalist okay I I love taking care of patients I and I love patients but the patients are absolutely not always right and if patients are being abusive to the health care team the organization needs to say to the patient it's not a family not acceptable that we can't have that here and I think I mean I'm you know you all know that you've had plenty of you know experience and you've done an amazing job and being able to do that so I'm not lecturing you that you all aren't doing this I'm just saying in medicine generally it's something we still need to do a better job at so thank you anything else that just resonated and then we'll wrap it up yes please so the question was you know how do we identify the physician or a person help your team member at risk and I just I want to clarify something we don't we don't we meaning we don't it's not the person who's at risk it's anybody involved in an event that we think could be emotionally triggering for a normal human being right so anybody named in a lawsuit okay anybody who's been involved in adverse events so it depends on what the triggers so for example the way we had it the Brigham was if that the risk managers they all know who's been named in a lawsuit as soon as they knew and they spoken to the the defend and they now defend it they they sent an email to me as head of the peer support program and also the the chief medical officer and the and the physicians chair chief or what have you saying this this is a lawsuit you know just like a two-line thing already spoken to you know doctor so-and-so and then I would follow I would follow with an email saying dear so-and-so you know welcome to the club you know right you know just sort of like this happens it's very frequent in people's careers we're sorry we know there's could be lots of emotions lots of us have been through it here names of 10 of us senior people have been through it well and then I would assign one of those defendant supporters to reach out so that's that would be that trigger but that's less common obviously the more common would be there was an adverse event there's somebody always knows when something went wrong not a really minor one because those you're not going to really worry about and there could be people suffering over minor ones that we don't see and we're not getting the near misses for sure but at least the ones where people know something happened you get this you sort of train the whole organization or the people the key people to say when something happens just let the director of the peer support program now they don't you don't have to decide if people are you know suffering just be like oh there was a death in the OR so you know I would get an email from any like there was a death in the OR there's just like two years ago and I got you know right away an email from someone who was you know around the OR at that time and I just you know within two hours reached out to the attending I found out who with a residence where I made sure I signed a peer supporter to reach out to each one of those so it depends on the circumstance but the big thing is to make it like normalized we always reach out because yeah it's to and you know of course people couldn't self-refer if they want to they can it's just they tend not to well thank you again I really appreciate you're inviting me and anytime if you want I'm it's j Shapiro at mgh.harvard.edu you know that email so if you know you want to talk about it more ask questions or just you know give me some feedback I'm always happy to hear Thank you