Lauren Mednick, PhD - Are We Ready Yet?: A Review of 2 Years of Enhanced Surgery Preparation

All right, good morning, everyone. So today we're very excited to have one of our own, Dr. Lauren Mennick join us for our surgical grand rounds. Dr. Mennick received her PhD in child clinical psychology with an emphasis in health psychology from the George Washington University in 2005, since completing her training in Boston Children's in 2006. She has been working with the medical coping clinic in the Department of Psychiatry prior to joining us. In 2013, at that time, she was promoted to the director of that clinic, as well as the outpatient psychiatry service, and then she joined our department in 2020. Her time in surgery was previously split between providing consultation and short-term treatment to patients in the Chlorrectal Pelvic Mopin Maintian Center, as well as building a program, which you'll talk about today, to enhance pre and postoperative psychological services for the larger population scene in surgery. Dr. Mennick's clinical and academic focus is on helping children and families effectively cope with acute and chronic medical conditions, and she has a particular expertise in passion for preparing patients and families for medical interventions. So to this end, she has written about and taught many lectures on this, and both locally as well as nationally, to help medical providers and families see the importance of psychological preparation for procedures. So her focus today is gonna be on, are we ready yet, a review of two years of enhanced surgery preparation, and for this talk, we're very excited to invite Dr. Mennick. I'm very excited to be speaking to some folks in person without a mask on, that's very exciting. So, thank you for inviting me, and thank you guys for coming in person, and the folks that are listening from other places. I'm happy to report on two years, because I think I have a lot of really great things to report, not only of what I've done, but what I've learned. I'm listening right now to a book, Think Again, by Adam Grant, about the power of rethinking and constantly learning, and I have learned a lot and been humble a lot, thinking that I knew sort of, the perfect way to prepare kids after doing this, I was a child life specialist first, starting in 1998, and I got it all, and I really have grown a lot in the last two years, which I appreciate so much. So, let's talk a little bit about what I will be talking about. Oops, how do I? So, my goals today, I'm gonna spend a little bit of time reviewing some of the stuff that I spoke about two years ago. For many of you, this will just be a review, for those of you who are new to the department, it might be new, but won't spend too much time on that. Talk a little bit about my role, and sort of the interventions that I've come to use very frequently with most children I'm preparing for surgery. I'll talk some about my data, so what are the referrals I'm getting, but also I've collected feedback from families, so I'm gonna give you some ideas of what families are saying about the services that they're getting from me, and how it's impacting the services you guys give. And then I'll talk about what I've learned, like I said, and what my next steps are gonna be, so that in two years, when I give grand rounds again, I can have an even bigger presentation. So, what makes a visit or a procedure or visit successful? And this is a slide from two years ago, and you might recall that I said that most physicians and surgeons would say completing the visit with a good technical result. So, meaning I get the surgery, and there is no complications. The appendix is out, and we are good, they are discharged, right? But I would add to that, and the child feels safe and secure and is willing to return. So, so many kids, my favorite story, and I probably told it a couple of years ago, but I'll retell it because I think it's really powerfully linked to this concept. I was working with the simulation center on developing a SIM for patients with autism who are getting EEGs and putting the leads on their head. And I asked them, and they said, oh, it's very complicated with these patients to complete these visits. So, I asked the test. I said, well, how long do we don't complete these visits? I want to get a sense. I'm a data-driven person, so I want to see how much I can improve what you're doing. And they said to us, well, we always complete the visit. So, now I'm confused, like, why are we doing this simulation, right? Well, it turns out the way they always complete the visit is they've proposed the kids. So, yes, we can hold a kid down and give them an injection. There are things we can do to make sure we finish the technical piece. But how can we ensure that we're giving kids a good psychological experience? You know, we can talk about psychological safety. But it's true in medicine, too. How can we make them feel safe? And maybe not. I have to be to return. I always say to kids, if you like having medical intervention or you love being at children's hospital, you probably need to see a psychologist. At the end of the day, I'm not expecting that my interventions are going to make them love having surgery. But maybe they're a little less scared of it. So, again, some reviews. So, why is preparation important? And expectation is everything. So, you know, kids and parents do better when they know what to expect. So, we know a major predictor of depression and anxiety in general, so outside of the medical realm, is having expectations that don't need reality, right? So, if you go into a medical setting and you're thinking one thing and something totally different happens, you're going to have a hard time. So, giving information is going to be really important. And while you guys are pros at giving sort of the risks and benefits and the basics, I can delve into details of what's going to be on your body exactly when you wake up. How long will it likely be there? Other things like that. I'll give you a hint into one thing I learned here is I used to make a statement when I first started that my role was to make it so that there was no surprises. That's not a really good way to talk to children because the reality is, is always surprises. What I really trying to do is minimize surprises. And so, you know, surprises might be very minor. Oh, they woke up and they thought they'd have one IV and now there's two IVs. Most kids would be okay with that. There's other types of surprises that most of us couldn't predict, you know, a complication that happens with surgery. So, I'm very careful to say, here's the information that I know. And most likely, this is what's going to happen. Occasionally, something different will happen. But usually, this is the way it goes. But we're going to try to make it so there's very few surprises. I think importantly, preparation for surgical procedures can improve lots of things. So, not only can it improve anxiety and the way the child is feeling emotionally and the parents, but it actually can improve medical outcomes. So, we've seen, this is Zeev Kain. He's an anesthesiologist, a reduction in analgesic consumption, emergence of delirium, recovery time is shorter, and behavioral channels are at last. And, you know, I think it's also important that we know that a medical experience and current time is going to impact how we think of medicine and then interact with medicine in the future. And so, you know, what we do now impacts the child moving forward. I worked with a kid recently, actually, and it was a kid that was having a Eurodynamics and VCUG went under anesthesia for some scopes and is going to eventually have a bigger surgery, but I sort of prepared him for that. And the story behind him is, and this was a kid actually coming from the Midwest, who'd been treated in an outside hospital and had a lot of medical trauma, I will say. And according to him and his mom was told a lot of things by doctors that didn't end up happening. And so, he viewed that as he was being tricked by physicians. And those are the words he used. They tricked me. You tricked me. You've never met me. How do I trick you? But that's really, you know, one experience in medicine, usually colors Paul, experiencing medicine. Now, this kid thinks all doctors' trick him say, I'm not going to give you a shot and then give you a shot, which is the kind of things he was describing happening to him. So it's really important that, you know, we give them good experiences. And then the other thing that I think is important to know in this is in a more recent study, that when parents feel less anxious, they actually report higher ratings of satisfaction. So in total, what I'm saying here is that every child should be referred to me, right? Because we're going to make them feel less anxious. I'm going to help them prove your medical outcomes. And I'm going to give you a higher satisfaction rating. So really, that's, we could end the talk right here in my mind. All right, so let's move on a little bit to my role in general surgery and what I have been doing with these kids. And some of this, again, is a bit of a review, but some of it will bring some new stuff to the forefront. Okay, so my primary goal, and this has sort of been over the last two years, how I explain what I do to children and families is sort of evolved to, I'm a communicator, and that I'm the go between. And so really, and that's what I've learned is sort of the essential if I had to like break it down to what's the most important aspect of my role, I would say that is it. And so what I mean is, first of all, I gather a lot of information from children and families about past experiences, what works for them, what they're afraid of, what are some things that would make things easier for them. So many of you might know, if you've worked with me with different patients, that typically, and ideally, I see a kid for two sessions before surgery. So the first session is really that evaluative session where I'm gathering a lot of information. I'm probably giving them some wisdom, giving them some tips, but that's not the main role. Second session is really where I'm giving them a lot of the feedback, a lot of the information about what they're gonna experience, teaching them some strategies, and then we usually meet once after, so sort of debrief with them, but also learn how I can improve what I'm doing, and how we can help other kids do better in the future. So keeping that in mind, my role as a communicator is I'm gathering information, and then I'm going to feed that all back to the medical team. So many of you have probably received my emails either individually as a group when I send it to certain patients, seeing notes I've written, I try really hard to find different ways to communicate the information, and I'm always looking for feedback and how to better communicate that to folks. And I've been so impressed actually about how often, I used to think nobody reads my notes, like what's the difference? I can just put them in there and nobody looks at them, but I've been so impressed from what family says to me around people remembering things. I had a family recently tell me, this was a kid who wearing the hospital PJs was gonna set off alarms. And so I communicated with child life and the pre-op nurses, I said, please let him go with Beth, which is close, if possible, which they're usually pretty good with in those situations, but somebody had left the PJs on the bed. That's what they typically do. And so the family was walking the mom's homey. We were walking towards the bed and the child life special saw them, and before my kids could see them ran over to the bed and hit them. And you know, just she said that felt so good that they clearly had heard all the stuff we told you right away I felt relief that I knew my concerns had been communicated to the team. So part of my role is communicating to the team. Part of my role is like the first point says is preparing the family, giving them information. And then in that second session, I typically review also some tips and coping strategies that the kid might find useful. All right, so my top side interventions that I do. And the first one might be surprising to some of you, because this is probably if I had to choose one intervention, this is actually what it would be. Educating parents. So it's not actually working with the kids. It's about educating parents. And there's a few things that I would educate parents on in particular. One of them is the importance of staying calm, the calmest catching. So what we know is that over half the variance for how a child reacts in a medically stressful situation is related to what the parent is doing. So one of the things that I talk to every single parent that comes through my office, and or un-assume to my office is the importance of them staying calm. And it doesn't mean they can't acknowledge it. They have worries for feelings. It's actually good to acknowledge these things for their kids, but there's a time and place. When you're standing and pre-holding, not the greatest place to fall apart. And that's what we're all human things. I am very careful to talk with parents around things happen. And we say things or do things that maybe later we want to do differently. But for the most part, trying to stay remain calm is really important. Another piece that I always talked to parents about is the importance of honesty. That kids, like I said with my story with the kids who had the Euro Dynamics testing, that when kids are given information, that turns out not to be true, they will develop a distrustful relationship with the person who gave them that information, but also the medical community. So even for my own children who believe it or not are afraid of needles, and it's sort of embarrassing to take them to the doctor, given what I do, I always call the pediatrician before any yearly checkup to confirm we can get chats or not, because I want to make sure that I'm honest with my kids. And I actually talked to parents that I work with frequently about if you tell them there's no chance, and it's not an emergency. And we get to the pediatrician and they say, oh, we actually have the question available. We'll give you today. I give it a choice to the kid. Well, I told him he wasn't going to have any injections today. So is it necessary we get this today or could we come back another time? So I think honesty is really, really important. Another area I like to educate parents on is what they might experience in their kids. So, and this is something I actually learned to prepare them for. So one of the first few cases I saw, I got a frantic call from the parent afterwards. And I'd say I don't even remember what the surgery was, but the parent was very concerned that the child wouldn't look at the surgical site. And this was several days out of surgery. And it was a younger kid, five or six. And I thought that was totally normal, but this parent had totally planned it. So now one of the things that I educate parents on is some kids aren't going to want to see their new offspring right away or the spar they got right away. And as long as they're letting other people, meaning doctors, nurses, you take care of it, they don't need to look. Eventually, we're talking a week or two down the line, they're refusing to look. We might want to think about strategies to help sort of expose them in a slow way. Can I explain to you what it looks like? Can I take a picture of it for you? Until eventually they're comfortable looking with something that maybe will be with them for the rest of their life. But in the initial phases, that's totally normal, that's a look. So that is something I've learned to kind of make sure that I just say to all parents because it's variable. Some kids are a little scientist and right away, they're like, I just had a kid. The other day asked me, could he keep his, or could he see his abnoids after they take them out? And I was like, well, you can ask the surgeon, I know. And he said, well, if I can't see the actual abnoids, can the doctor take a picture of them? So every kid's a little different of what would be interesting to them. But educating peers of I can help parents know exactly, and so much of my role, when I make these checklists that we'll talk about in a minute, the pictures of what they're gonna experience. I'm actually teaching the kids, or teaching the parents what they're gonna experience. Looks like it's a picture list for the kids, but the parents feel a lot of relief about what they're gonna see. So my second intervention is the obvious, talking about worries. So many parents and several have come in, and their kid doesn't know about the surgery yet. I usually know about those cases in advance, and so I'll bring the parents in first and talk about it. And oftentimes I'll say, if I can communicate with Admin before, like I think it's important that the kid at least knows about in general, that there's a surgery in the future before they come see me, so that it's not, they know why they're coming to see me. I think, but they've often not talked openly about what specifically they're worried about, or a parent hasn't acknowledged. I often say to parents, it's okay if they say, I'm worried that something bad could happen. Don't say, oh no, nothing that will happen. You just dismissed their worry. I can imagine, you're having a surgery the big deal. You know, and that might feel really scary to think that's something bad could happen. So really helping model for the parents how to talk about worries, but also give the child an opportunity to talk about these things. I always start with kids by saying, so are you having a surgery? Yeah, and then just because I always want to make sure that they know why I'm coming to Boston Children's Hospital next week, because sometimes they'll say, I don't know, I'm like, oh no, oh no. But usually they'll say, oh, I'm having something to fix whatever. And I'll say, well, why are you doing that? And so I want to get their understanding also of what's happening. I also try to find out from kids, if they, not if they want the surgery, because I always say to kids, I'm like, no, I really want the surgery. There's not nobody's, I'm like, oh yes. You know, I was listening to what Dr. Vischman said during the meeting last week, and I loved that idea of elective. Like who's electing to have mostly surgeries? And I'm maybe there's a few that are slightly, you know, but we're not electing to have surgeries here. And I think, you know, so I always say to kids, you know, nobody really wants a surgery. But, you know, it sounds like this surgery's gonna help your belly. And so if it was up to you, even though you don't move it, you think it's the right thing to do. Because I want to also engage how much is this kid interested in having this? A third intervention that I typically do is information of familiarization. So we're gonna talk a little bit more, this is, you know, giving that information about what they're gonna experience, what's gonna happen? Importantly, the information I give kids might be a little different than what I give parents. I want kids to know exactly what they're gonna see an experience. So when they are asleep during the surgery, they don't need to, most kids don't want to know anything. Okay, they want to know when I'm sleeping, that Dr.'s usually special tools to fix my belly for whatever it is. But then they want to know when I wake up, here's where the scar is gonna be, here's how big it will be, it'll be covered by a bandage exactly. And I do have some kids that have the same kid with the abnoids, wanted to know, could he see the tool that takes it out? And how do they take, I mean, he had such questions. And so there are kids. And that's why it's so, I'm very fortunate that I have the time that you guys probably don't have to get to know these kids really well, in that really well in 90 minutes. But still, to figure out, like, what kind of kid is this? Do they wanna know that level detail? Or do they wanna know just what they need to know when they need to know it? Because that's an important thing. Every kid needs to be prepared with what they're gonna experience before they experience it. When and how much, that's less of a, that's more than art than a science. And so the other thing that I would say about information is that similarly to what I was just saying, there's certain kids, most younger kids, I'm gonna try to prepare them like the day before, with detailed information. I'm wanting to know they're going to the hospital and gonna have their belly fixed, the general idea more than a day before. So it's not like, wait, what's happening? But the details of it probably the day before. And when I say younger kids like six and under, so maybe even eight and under, again, it's gonna depend a little bit on the kid. And so sometimes that means that I meet with the parents because I can't, let's say they're surgeries on Monday, I don't wanna prepare them on Friday because then they have the whole weekend to think of all the details about the Holy Capital or they're gonna have, and the drain. So I will then meet with the parents, show them all my preparation tools, email them to them, teach them how to prepare their kids, and the parents take on the preparation. And then there's other kids like I said that want to know way in advance, one of these kids was so worried, a kid I was working with, and again, I don't remember exactly the surgery, but what she thought was gonna happen was so much worse than the reality that I ended up giving them all the details about four weeks before because I thought it would be calming and it was, and in fact, and this was a kid on the autism spectrum, he used the checklist every time he would say, am I gonna have his mom say look at your checklist, see if that's on there, if it's not on there, that's not the plan. So there's a few different ways that I give information to kids, and one is my beautiful checklist, and this is just an example of one, and it just goes through the beginning parts of coming to the hospital. It's more complicated with the changes in the ORs, and where they go for pre-ab后ening, and where they go for, you know, they might be in a private room, they might not be, so I try to, you know, I do a lot of flexible language in talking, but these checklists, like I said, I use for kids probably eight and under, I keep the pictures on there, some kids would prefer looking at pictures, obviously older kids with autism or other things, I might still leave the pictures on, and then for some older kids, I still make them a checklist, I just remove the pictures, and the reason I make the checklist is, we've all been in situations when you're anxious, and you can't remember, because during the time you gain the information, you are anxious, and so when you go to recall it, your memory isn't as good, and so it really is helpful to go back and be able to look, and again, parents really utilize these things, so some kids use them as a true checklist, you might have seen that before, other kids, it's just sort of a tool to prepare them. Another tool that I use is medical plan exposures, so I always like six or seven or under, one of the first things I ask their parents, but I'm thinking about ways to help prepare a really young kid, is I say, do you have a medical kid at home? And I'm actually quite surprised at how many families don't, especially for medically complex kids, and I say, can you order one today? And I think, you know, that's a great intervention for a young kid, just letting them have that exposure, so that when they see those things, it's not totally new, or if they have already seen those things, they can start gaining some mastery over it and feeling less afraid. And then exposure, there's plenty of kids that come into my office that want to know what an anesthesia mass looks like, so I have one in my office, we can touch it, we can look at it, and there's other kinds of medical equipment that we can show kids in advance to make them feel more comfortable. So my virtual 360 tour, and this is something I created with the SIM Center, and I'm about to take you on a tour, and you will be reminded of days long ago when you were in the old situations, but this is still the tour I'm using. I have pictures that aren't kind of, you know, very still pictures of the new areas, and I do show some of those so that the families know here's what the new waiting area looks like. But we've decided, and we've gone and gotten footage of Hale with the 360 camera, and we are gonna adapt this a little bit, but we're being careful not to put all the nice things onto the virtual 360, because some families aren't gonna get that private room, or their pre-op will still be in the room with lots of curtains. So we kind of give the lowest common denominator for everybody, and but let me show you, and we'll take you on a little tour right now, so you can kind of see what we created, and this was a lot of fun to do. And what we're working on now, I'm trying to, I don't know how to move that over, in this version, what we're working on now with the 360 tour is developing a script. So right now, this is not available on the web, it's only available by me kind of walking a kid through it. And the reason for that is that there's no voiceover, there's no things you can click on to get information, and we don't want anybody just like going through things. But what we're working on with the 17 right now is coming up with those scripts in the voices. So actually that's what I'm gonna do later today, is review the latest scripts and see where things are. So this is again, the old surgery check-in area, and I have still pictures of the new surgery check-in area, but the idea is still the same. Check in at the staffs, then you get your bracelet with your name and your birthday on it, you tell them that you're here for surgery. I always talk to parents about the nursery liaison, which is obviously, as you all know, over here before, I have a picture of where they are now, and I explain to them how they're gonna get information, and show them the parents a picture of the waiting area they'll stay in. I have many parents comment to me how helpful it was in recent surgeries to see the new area, and to understand that they'd be going back between the two buildings. I think it seems like a little thing, but it's quite a walk as we've all seen. It's not just, you know, not really just next door, you know, you're going up and down, and so parents really, I think, appreciate that sort of forewarning, like just so you know, here's what's gonna happen. And I just, I say things like, you know, some kids will go to this area, and other kids will go to the new building. And this is the old waiting area, but you know, you then, you're gonna go sit in a waiting area until somebody calls your name. And when they call your name, you're gonna go to pre-op holding. And we will keep this pre-op holding for the time being in the 360 tour, just again, because we want families to see this area at not necessarily think they're gonna get an individual room. So some of the things I point out here is the idea that you see that there's two chairs there. And so that way, if the family, if the kid does have two caregivers, two parents, I'll say, that's what both your parents can say if you would wait with you until it's time for surgery. I might point out to them that pajamas, and if it is a kid that doesn't want to wear them, which does happen occasionally, you know, even if they're there, you don't have to put them on if you talk to your doctors and they say it's okay. So we kind of go through, if you look over to the left, we can see child who even some toys. So I try to show them some of the fun things. In here, and then I'll show you guys your favorite room, I think. And yeah, so I'm gonna spin you around, and then I'm gonna tell you a couple of the things that I tell kids. So probably if I took a vote, you guys would probably guess what the two biggest fears are of kids going into surgery. Can I ask the people that are here to come up with at least one of them? Needles, that is one of the biggest fears in action when I correct misconceptions. One of the big things that they're afraid of is not, I can pretty much assure them unless they're much older kid, but younger kids, I can pretty much assure we can probably get that needle when you're sick. You're probably not gonna, but then they think that the needle's still there when they wake up. And so I bring out an IV kit and I say to them, look, it's a straw. So what happens is the needle guides it in, and then we take the needle out, and most kids do not know that. So that is a way I can help them feel better about that. What's another fear that kids probably have very frequently or adults, anyone has having a surgery? Not waking up or waking up during the surgery. So our friends in anesthesia, allergy, that's who they do not like. So that is number one, those are, number one and two, those are my two top fears that kids describe to me. And so if we have our colleagues, Manesthesia here, please understand I know I'm simplifying your job, but it helps kids when I explain to them, it's a doctor in the room that their number one job is to make sure you stay asleep, and I talk about it as a special kind of sleep, it's not like falling asleep at night, it's a special kind of sleep that even if I tickle you or shook you, you would awake up. They use special medicines to make sure you stay asleep the entire surgery and don't feel anything. And that you wake up when it's time to wake up, and that's their whole job. So what happens if they didn't do their job? And you know, just cause they would get fired, and what they would get fired, and they wouldn't feel good about themselves because they wouldn't know how to do their job. The other thing I explain to kids that really seems to help is if you look around, I like, you know, I don't know, I haven't been into many of the ORs here, so I don't know the answer, but I don't know if you guys have all noticed how many screens there are in the OR. So in your own shopping computer screens, what looks like television screen, you know, there's so many. So some of the kids I have them go through and count the screens, and it's something like 12. And I say them, well, you think they're like playing songs? Like what are they doing in there? Like, you know, gosh, you know, and I don't know, I don't know, and so I explain to them about leads. And you know, because I do tell them, they wake up, there's gonna be stairs on them, and I say, there's that many screens watching to make sure that you stay asleep, that your heart's beating good, that you're breathing okay. And that's really reassuring to kids to see that. Okay, you know, to know, oh my God, they're really watching me. I'll show you this view. And oh, why is this not, let me see if I can get this bit. Oh, this mouse isn't readily sensitive. Let's see if I can get through it again. Okay, maybe I'm not gonna be able to go. I'll try one more. Okay, anyway, regardless, if you click on this thing over here and the arrow thing, and now it's not letting me even move with my mouse. Oh no. Yeah, let's see, oh, here we go. Okay, so if we turn around this way, you can see what it looks like to get a mouse. I always talk about the seatbelt, and I say, some kids will remember some of this and other kids won't, but I tell them about what it's like. And that's what the mouse looks like. We had one of the anesthesiologists look at this recently. I forget why. And they wanted us to change, and we are gonna make some changes because the person holding the anesthesiologist's mouse, I think. That's nurse. I said, well, I just won't show them the nurse. When we went and did these 360 views, we just ran to whoever was there. I mean, I am be patiently a thung nurse. So, you know, this isn't something that are not very realistic about it. All right, let me go back out. Yeah. That's all. And then at the end, if they go up to the ICU, I have pictures of the ICU, but if they're going to pack you, again, I can show them sort of the worst version of the pack you. And I show them in here. One of the things that I always prepare families for in the pack you, especially if they're gonna be in these not individual rooms is sometimes, first of all, it's something I've learned about talking about, especially with the younger kids, that some kids wake up really upset. And that doesn't necessarily mean they're in pain. And here's some different reasons why they might be really upset. Here's some things you can do to help calm them down. You know, so be so that parents are ready for it. The other thing I talk about is hearing other people. And I think that has been something that's been really challenging for some families. That their kid might be calm, but all the beds around them are screaming and yelling, and it's very hard for them to manage that. I think that's the idea of single rooms in a pack here. All right, so let me get back outta here. I'll take you back to my tour. Okay, so that's the B60 tour. Like I said, we're gonna, we have the new footage and we're gonna put it in. We were also really excited to be able to go in before the MRI machine was on and get 360 footage of that, which we were never able to do when we had an operating MRI. So we'll have some more things to show him, too. Fourth tool I use is distraction. And so the number one application, behavioral strategy for in a conference review that found for kids with pain or kids with anxiety is using distraction. So what's really important is figuring out what is distracting for that child. And so this is something I communicate to child life, I communicate to nursing, all different things. And again, one thing that a lot of families have noticed me is, oh my gosh, it was so amazing that when we got to the pre-op holding area, they had poppetal toys at the bed because you were told that they liked poppetal and right away they felt comfortable. So you know, knowing those little details are a big deal. And the fifth intervention that I typically use is sort of as motivators. And so this is this idea of, I often talk to kids about a brave review award. So there's two things that I always say to many kids, kind of even teenagers, but definitely school age down. I say, I gotta tell your parents two things. And I say, well, first of all, and I ask the kid, I'm like, when your home, most kids have access to a tablet computer, something like that, video games, are there limits on the video games you can use? And they say, yeah, I was like, no, you know what I said? So I'm gonna tell you parents something really important. Like the morning of your surgery and while you're recovering in the hospital, there's not gonna be limits, okay? And the parents are like, okay, okay. And the kid, all of a sudden, is a huge smile on. And so what I'm trying to, not trying to do is to say, so don't be worried, because you get to have a great reprise, or you get to be in your office the whole time. But I'm trying to balance it out, make something positive out of this. And the same thing with the reward, the life, say to parents, you know, sometimes something that helps kids is having a bravery prize. And so for older kids, this might be something they earn at the end. For little kids, we might develop a chart where every time they cooperate, they get sick or a surprise, or they get small prizes along the way. I have a lot of parents that end up going to the dollar store and getting a lot of little things, kind of like our treasure chest on the floor. Okay, so I'm gonna talk a little bit about my referral data now. So this is, oh, there we go. This is just based on the two fiscal years, so not October and November of the year yet. But I wanted to show that there's been growth. So the first year, I saw a 28 new consult, and the second year, 41. And just to review some of the demographics of who I've seen, I've seen kids as young as two. Actually, I think I saw one 18 month old after I put this out. A patient is older, 36. And all these family, any patient can benefit from learning new strategy. There's a survey, and we'll talk a little bit about the limitations of that survey when I get to a little bit more of the data, but that of the family set up complete of the survey, 53% of parents reported that their child had a surgery in the calf, which I think is an interesting statistic, because my assumption would have been that I had gonna have more kids that had never had a surgery. But maybe it's happening. Some have had surgery, and some have. And then 75% have said their kids have been hospitalized. All right, number of total visits again, this is the two fiscal years, and just wanted to bring this up to show, we've more than, I've more than doubled that. So we're seeing a lot more patients in surgery, less unique patients, I wanna increase that. But, and this is mostly three to four visits per each child. There's a few patients that have had sort of serial surgeries, and I have seen them in a little bit more of a typical therapy fashion throughout their different surgeries. So, being very slow. Okay, so, I do wanna know with that there are some referrals that I've gotten that I haven't seen, and the end here's only 39, which isn't so much over a two year period. And some of them are just not able to reach, and the 22% I believe are eight, and a canceled or no show, not interested when we finally call. I think the two that I would focus on is insurance coverage, which is 20%, which is like I said, six or seven. It's not that many people, it's all the different medicaid. So it's Vermont medicaid. And those families could work to get a single case of remnant, most of the time they don't want it. So we give them education on it, but most of the time that that means they're not gonna be seen. And then, it can actually what happens, and this is probably of all of them, this is probably the most modifiable thing, although it's challenging, is that sometimes I get a referral, and there's like, I'm searching in two days, and tomorrow my case totally booked. Many of you have worked with me that I will get a kid in, I will add in slots, I will do the best I can, but sometimes it's not possible, or by the time we reach the family, because it takes us two days to reach a family now, there's surgeries tomorrow, and I can't see them. So I think that's probably the only one that maybe we could work a little bit on, when we know what advanced that a kid is gonna have a surgery. All right, let's talk about the feedback from the families. What are they saying about my service? So I asked parents to complete a survey at three different time points through chat with childrens, and some of you might be familiar with this. It's a platform developed by Anastasia, and they were really gracious to let me do it without paying the fee. So what it is is it comes through your cell phone. So it's an app that comes or a questionnaire that they get text, and that's really nice. And I found I was using something else before, and my response rate was lower. And so when they can get it on their phone, I think it's better. And so they're asked prior to meeting me to fill out a very, I mean, these are less than five minute questionnaires, a very brief. Ask her, they meet with me and before their surgery, and then after surgery. And I kind of want to, the main things I'm looking at are their level of anxiety about surgery, and how prepared they feel for different aspects of surgery. And the surveys, I do want to note that many of the surveys in the initial year-ish were not sent to families due to error, confusion about whom to send them to. But I think we got things down to a science in the last few months, and every family is at least being sent to the tax, whether they do it or not. And the other thing to note, and just as a limitation, is that response rate is variable over the three time points. So as I was looking for, because this isn't a study, this is more of a QI type thing, I can see sort of who filled things out. And it's very interesting that someone might do time one and time three, or someone might just do time two, or someone might do time three. So this isn't ready for publication. Let's put it that way. But it's good enough for me to tell you and give you a general sense of what families are saying. So one of the questions that they're asked, oops, I'm sorry. Where is that? One of the questions that they're asked is, how anxious are you about your child's upcoming surgery and post-operative care? And so they're asked us at the time before they meet with me, and then after meeting with me. And what we're seeing is that, prior to their initial visit, 50% are saying they're very or extremely anxious. So it's a four point-like or scale music. And that 20% after meeting with me are still saying. So some families are just remaining anxious, but that we are seeing a decrease. I then go through a series of questions, asking them about preparation. So at all three time points, they're asked about how prepared are you or were you for the pre-op holding experience? And what we find is a trend in the right direction. So prior to meeting, very extremely prepared was only at about 50, I think it was, let's say I look at here, 50% and then after meeting, closer to 85, and then after surgery at 100%. So these are good numbers. Same thing, we're gonna see a similar pattern for, how prepared they were for surgery and inpatient stays. And then how prepared they were for returning home. Because I also think that's a really important thing. And I should add, when I look at the visit count, which is a lot higher than the unique patients I see, there are also a few patients that when their surgery leads to a new procedure, a new device, so they have an osteomy now, or they have a ocecostomy or a G tube. I will often see them for a few sessions after, because now we're adjusting to having this new piece of equipment on them, or I have a tube that's then gonna have to be removed in six weeks. And so I might see them for a few times and then prepare them for the tube being removed. I worked with Belinda on a bunch of these cases and what I love is she's open to the idea of the kids putting the sit and pulling this about and the kids have loved it. And it's given them a lot of empowerment and I think she's enjoyed sort of these kids being excited to help move onto the next stage. I mean, look at that, right? How likely are you to remember from undocumented to other families having surgery? So 100% works, extremely likely or likely. This is my husband who's a PhD researcher, MD Ph.D. here. He likes to tell me this research study that I think was in JAMA, you guys would probably know when it's about, and it was put out on April Fool's Day and it was what percentage of people who jump out of a helicopter without a parachute die? 100%. There's like these obvious research studies, right? And I sort of feel like my intervention is sort of that obvious thing. It's hard for me to imagine a family not finding it useful. I'm lucky in that way and it helps me feel good about myself, so that so many families appreciate what that I've only added into their experience. So to summarize all parents who completed the surveys, I'll say and again, it is biased because only some parents completed the surveys feel less anxious and more prepared after meeting with me. Interestingly, like I said, anxiety's harder to change than preparation and I think what that comes down to is anxiety can be a trait. So preparation is state, right? You're prepared for something or you're not and that changes in every situation. Anxiety, there is state anxiety, meaning like this situation makes me really anxious, but in general, not an anxious person, that's trait anxiety. But I think those families that have trait you state and when you have the two, it's hard to change with one intervention, they're trait anxiety. And so I'm thinking of a family that I very recently worked with that. I felt like everyone went above and beyond to make this family comfortable and provide information and in most of our assessments, this was a relatively minor surgery. Yet I know that this moment is still raining here inside the house. So a necessary trait. I won't read all of these, but I did ask them some open-ended questions. And so what did you find most helpful in meeting with that tremendous? I think the ones that stand out for me is dividing a plan that would allow her to feel comfortable. The tools she used to prepare, I got her excellence, our drivers relied on them before and after the procedure. Confident about the admitted surgery and the cubby sets prepared ways to engage and include kids, so giving them some control and mastery. Another question I asked, so what are the most important things you learn for meeting with that tremendous? And the idea of keeping your own anxiety under control. So parents are hearing that. Walking through the whole process, so many families report on that third visit. Like it was so helpful to have seen pre-op. So when we got there, we're like, we're all pre-op, or what is it or I look like, oh yeah, that's familiar. Including him and keeping a chart, I think he tracked up his briefings he did. And then the final question I asked is what strategies are most helpful? And if you look, many people mentioned the checklist. So very simple intervention by having that concrete thing is really helpful. Being very particular to some kids, like finding out their particular desires, not wanting an ID, allowing them not to wear gown. The works he told many people mentioned these works he saw. I creed it, it's actually kind of fun. I think a scavenger hunt of the hospital that kids can do. And one page is like a true scavenger hunt. Like find the flag in the room or whatever. And then the other pages are fun versions. Like it lists the alphabet. Can you find something with a letter A? Letter B, letter C. So there cognitively taxing things that engaging activities that the kids can do waiting and pre-op holding when they're in the hospital. And I have some kids that come to me at the third session and they come to me at them all. And I'm like, oh, were we gonna do a prize for this? I didn't know, but I think the kids, it's just a little tool that I can give to families that they can bring with them. So let's talk about, for a moment about what I have learned, how that's gonna impact moving forward. And I've learned a lot. Like I said, I think I've been humbled to realize that there's a lot more that I didn't know or didn't do the best way. And I love the feedback from the family. I mean, I ask every single family that I meet with have follow up. Tell me other things I didn't tell you are things that the way I said it wasn't helpful or other things that I could do to make things better. And I think that I was gonna write up a paper at this point, it would be something about that because it's the unknown. The families could only tell us that. We can't make that guess. So one of the things I've learned is, I'm gonna go back to my first presentation two years ago and I ended with a slide that says, who should you refer to me? And I said, you should refer the kids that seem really anxious. You should refer kids that have a psych history or a history with challenging medical procedures. They're having a procedure that's really challenging but really challenges in the eye of the beholders. It's just invasive or non-invasive. Every kid is gonna decide and you were not gonna know who's the most anxious just because they're not showing you that they're shaking in their sheet or crying. We don't know how they feel. So I'll change that and if I could do that again, I would say who to refer and my answer would be everyone scheduled for a surgery. So I think there should be 100% recovery. Dr. Fish and I kind of raised his eyebrows. Yes, we're gonna have to hire more psychologists eventually. But I think what you can see from the data is that everybody finds a beneficial and who are we to say who would benefit from this or not? So what I'll tell you is that in the front and they keep them actually at the front desk too, I have like this, you guys all have them too. It's kind of like a little bookmarketing and on one side is actually just tips for working with kids going to surgery. So all families would benefit from this even if they never see me because it has the tips on it, like about call miss catching. And then the other side says, why would you see a psychologist before your surgery? And it gives my information of how to make call in. And I have had about two parents call directly. And I have had some parents say, I don't know why nobody told me about this before and I had to figure this out in my own way. And so I'm gonna encourage all of you, I will let you know if somebody's not appropriate for a furl, but to this point, I really haven't gotten a not appropriate referral. The other big thing I've learned is so as was said in my introduction, prior to this role, I was six years in a leadership position where I had 35 clinicians and about 20 trainees who I was responsible for their performance. And it was a lot. And I was looking forward to this role but I kind of work on my own a little bit. And I do, I mean, there's times where I feel very much like, I am just in my office seeing patients and like, who else is here? But really there is so much collaboration. More than I've ever done with communication and with child life, with nursing, with surgery, with other surgery departments because they are some of the people referring. So that's just been amazing. Also, I think probably the biggest thing I've learned is that my information is only as good as what I'm given. And so I've learned to ask questions in a different way. One question I didn't ask you all in the beginning was, are they gonna need a test before they leave? And nobody thought to tell me that. And so there'd be kids that were getting a vocal cord check and I didn't tell them that. And now they're, it's not gonna be good to tell us about the vocal cord check. So what's gonna be on their body? I usually just say, what's gonna be on their body? Now I say, well, they have a dream. Well, they have a folly. Well, you know, so you guys are gonna get these emails from me and you'll be like, we're going through this again. But every kid's a little different and I wanna get the best information I can to help kids, to help prepare kids. So just briefly, so we'll have a couple minutes. If there's a question, you know, what's next? I want to increase referrals, like I said. Just a moment on this, Explore ways to better communicate with A anesthesia. What I mean by this is, I can, I know who the surgeon is. I know who the Priyac nurses team is. I know the child life on the different floors and the Priyac holding. And I can send you guys my email that lists recommendations. And what's hard is I don't know who the anesthesiologist is gonna be. And so oftentimes the fears are around, do I have to be awake from IV? Can I get a oral premed? All these things that I can't answer with 100% certainly. And I also can't communicate with the anesthesiologist. And what I've observed is that there's variability and that some of that variability is based on what that anesthesiologist is, you know, comfortable. So some families will say, a parent will say, can I go back to the OR? Am I general answers? No. But I'm aware that some anesthesiologists let the parent go to OR. And you know, so like when is that exception made? And so I would like to just explore ways. How can I better communicate and, you know, speak with those colleagues? Collect more and better data and create some additional resources to give to family. So I've created a bunch of education sheets that are actually on the family ed about preparing for different procedures. But I'm gonna work on that 360 video so that it's on the children's internet. But I wanna come up with other resources because while I want 100% referral, I can't see everybody. Read minutes for questions. Ha ha ha ha. Well, thanks so much, Lauren. I really enjoyed that. And it's great update from a couple of years of your activities. And, you know, I wanna reinforce that. Although Dr. Vendek showed us her self-administered satisfaction test, right? And it looks pretty good. The hospital does anonymous surveys through independent company that all encounters, many encounters that parents had the opportunity for patient opportunity. And we actually transparently circulate them in the fact that the people see comments about themselves and their colleagues all the time. I haven't seen only 100% positive comments from the families who had experiences with Dr. Vendek. And so that's an independent validation of her of her satisfaction. I've similarly heard nothing about positive comments from faculty members who have referred patients for experience. As you can see from the numbers, she has plenty of capacity but she's dealing with some of the more complicated patients. So we all should be aware of the opportunity. Maybe not to send every patient as we do thousands of operations per year. And obviously she would have time to see all of those. But it is something that almost all insurance carriers recognize and provide for. Wow. Having anxiety, Dr. Vendek. And as you can see, she also, although she works for the Department of Surgery, she has the freedom to see patients who are colleagues in our interdisciplinary clinics, our multi-special clinics. And even in your neurology patient who has nothing to do with interdisciplinary things is welcome to consult her as long as she has capacity, which at the moment she does. So you guys are my priority. But if you're not filling me, I'm going to take that. With the experience you've had, feel free to let others know about this capability. It is pretty unusual. As pediatric providers, we all like to think that we understand how to make parents and children feel less anxious. But there are some patients that really could benefit from a professional who does that and is trying to do that. Any questions for Lauren? Dr. Medik, unfortunately I stopped operating before you came on board. But I think the service that you provide really is remarkable. And I just underlined two points from your presentation. First is the anxiety that parents, because through decades, if the parents were anxious, the kids were going to be anxious. And so dealing with that, I remember I used to tell the liaison nurse and the nurses in the pre-op area that we needed some nebbi-lised isopam at bedside for some of these families, because as a parent, we get themselves as a red of dub. You could see the kids going down that tube with their anxiety. The second thing is about kids and answering their questions. And I think it varies how much you tell them from when they're little to teenagers and adolescents. And I always describe to parents that you deal with it like sex education, as long as your kids answering, asking questions, you answer them as honestly as you can. But when they stop asking, don't push more information on them than they're ready to digest. And if there's adequate time before the procedure, they'll come back and ask more questions. But I always used to find that the parents level of anxiety was often completely reversed from the severity of the procedure. In other words, the ones who were facing the biggest challenges for the kids were usually more tranquil than the ones that were just, I think it was intrinsic to the parents' nature that their anxiety was something that was all good. Congratulations on all the work that you accomplished. Thank you. Yes, I would agree. I always say follow kids leave. And you can read them a certain way, but then let them decide how much and when. And you know, often I'll be working with a family and the kids will start clearly changing subject or whatever. And I model to that family. Like, maybe you don't want to hear about this right now. Maybe another time. Maybe Mommy and Daddy can talk to you more about this when you're home. With some of experience. Thank you. Thank you. Others? Lauren, thank you. My question is about parents who want to, and this happens occasionally, especially with school age kids, I think, where they want to sort of not fully tell the kid what's going on. And sort of want to trick them almost into coming into hospital and all of a sudden, they're being held down to getting anesthesia. What strategies do you have for parents like that that we can start in the clinic or talk about with parents? There was an anesthesia grandmothers that I found out about. I was like, why didn't you guys invite me to this? That a kid was brought in and the parents wanted them to be knocked out. And they had no clue why they were coming in. I think that's a really great point. I think parents are coming from a good place. So I think first acknowledging I can understand why you think telling them might make them more worried. So I think just, first of all, meeting them and where they're at, kind of thing. Like, I get that. However, we know that giving kids some and for it, that medical surprises will make it much harder for them to cope with this current situation and will make them afraid of medical stuff in the future. And that's a really good point to say, you know, there's a psychologist here that works with how and when to tell kids. Because you're right, we don't want them to have too much information that they're really anxious. So I think joining with them a little bit and acknowledging you understand where they're coming from. But that kids need some information in order to do better and even telling them, you know, we know medical outcomes are even better when kids are prepared. Because they're more cooperative because they know what's gonna happen. They know why. But I think I always try to remind myself, okay, they're coming from a good place. You know what I mean? Well, I think we're at time. I really want to thank you so much. Not only for your talk, but you also know that it was actually a documentist idea that she'd join our faculty. She came to me with proposal with a financial platform with how she could be helpful. And that's sort of the food we treat. So thank you for all of your attention. And thanks for having faith. All right.