Dr. Yue-Yung Hu - SECOND Slides into THIRD: The Science of Wellness & Inclusion

D, an elevating cavern, I'm to a panelist. We're going to close out of that actually. So that will we don't have that kind of echoed effect going. We can just hit continue. If you need any radio, we can actually be camera as well. Oh, it's like you have two points. And then from here, we can do it through to load up your PowerPoint. And then we'll share your screen over on zoom. So that way we can have this live on the screen. We'll be all good to go. Powerpoints up. I'm going to share. Yes. Share screen. And then we'll start it. The thing is, I can see the PowerPoint, the PowerPoint screen right there. And then can I have you just talk a little few times a couple of slides? Yep. And I got a change. So salty. So. So. So. Once you see that little green light hit, then everyone will hear you. You're going to go. And there is speech control available right here. If you need to raise a lower the volume of the web reason. Okay. Any questions at all about the setup? How things are going to operate or things to happen? Thanks. Lovely. So otherwise you should be good to go. I'll leave that microphone on for the interim time. So just know that you got a hot mic here. Thank you. Thank you very much. All right. This is not. It is not. All set. That's what we do. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. All right. Well, good morning, everyone. When we go ahead and get started. So I have the distinct privilege and honor to introduce this year's governor of course. Old Seite Sürger Clapton is the chairman of legislative board again visiting professor, but before he gets into a few details regarding that I just wanted to acknowledge Stuart and Jane Whitemen. Many of you in the audience know to me that the ministry of wowing certainly. A Sam, �ing benefits far as possible, especially towards the department. to the white men's for their ongoing generosity as well as their our gratitude to them. As far as the white men lectures concern typically what we do is we highlight folks in our field have really made tremendous advances in the field particularly with respect to clinical outcomes research. This year is actually a bit different. The topic and focus is a bit different and that's not because it's any less important and certainly because it's not any less impactful and this has to do specifically with surgical culture and experience with training and how that relates to wellness and job satisfaction and ultimately burnout and as many of you know this has really been a hot topic in surgery over the past five years specifically because of issues with attrition and workforce considerations but also because they're now clear disparities that are starting to become fairly well characterized. And so today we're very lucky to have your wrong who from Lori Children's Hospital who I think many of us recognize as one of the really kind of authorities on this topic this very important topic. And as far as our background she's a general pediatric surgeon as many of you know Lori children she's assistant professor of surgery at Northwestern and I'm her school of medicine. In when you review her CV it's clear that she has profound straight create in the space. She has over 60 peer reviewed publications a number of first and senior authorships and journals you may have heard of including New England Journal as well as JAMA. And I'm talking about Mama JAMA not the baby JAMA surgical journals right but the big one. A number of invited lectures on the topic. She has been the PI or co PI in the number of very impactful national studies with the public. Studies which have characterized this issue and she's been featured in the times for. Where to go from seeing. I'm giving in New York Times as well so. Sarah. Hey, okay. Anyway. And so she is the real deal when it comes to this topic and a lot of what she's going to talk about has implications for beyond surgical training. So we're really interested in what she has to say today. I'm going to say Dr. Hi, thank you very much for having me. It's an honor to come back. I was a resident here and this is absolutely the place that inspired me to be a pediatric surgeon in my PGA for your wish was like a little late and. I was probably the whole separate conversation but anyway, you were the most supportive place when I decided to make that last decision and the most inspiring place. So it is super great and meaningful to be here. Alright, so. My disclosures, the second trial is funded and the third trial are funded by the ACS and the ACGME. I'm going to be collaborating with the APDS, the Society of surgical chairs and the American Board of Surgery. A lot of what I do is informed by my experience being an Asian woman in surgery. I'm also a health services research by training. I did my research time at the Bergamoth Greenberg and I came to Northwestern to work with Carl Bielmoria. They're all hard quality and safety people and we sort of happen to be in this education space right now. So the data I'm going to show you come from two different sources. The first is a survey that's given out after the absite exam every year. It goes out to all clinically active residents training and accredited programs. It is elective and confidential has a response rate of 77 to 99%. So it enables us to really get a sense of what's going on nationally and the other data source is qualitative. So between 2019 and March 2020, we traveled to 15 general surgery programs around the country. We conducted 398 interviews and focus groups and these have been deductively and inductively coded since then. And so you'll see some of that data. So just to start with the overall trajectory. I started at Northwestern. Carl had conducted the first trial, which resulted in a change in Asia at GME policy, allowing programs to eliminate these duty art restrictions. So actually it allowed for more work, nonetheless, that's a point of confusion I find frequently. And one of the findings that drove this change in policy was this that residents without those restrictions actually had better well being after their PG by one year. So I don't know what was things like the virus. Because other of education culture optimization through targeted interventions based on national comparative data. This is obviously a terrible four-store acronym, but you get the idea. The reason for the culture optimization is because, like I said, we are quality and safety researchers, and we tend to think of things as a systems approach. So I think everybody is pretty familiar with this diagram. It's reasons with Scheeze model of error in which multiple layers of defense exists within a system to prevent risks from turning into adverse outcomes. So for example, to prevent a pulmonary embolism, we incorporate prophylaxis into the pre-op checklist. We have standardized order sets so people don't forget to order prophylaxis, and we train nurses in what to say when patients refuse. Analysisly event, we started to look at wellness, and what do people do to prevent burnout? And having now canvassed the national scene on wellness institutions, talk about picking more resilient physicians. They talk about emphasizing self-care, including the six-hour CME on happiness, and they throw pizza parties. And how is that going for us? I think I tackled maniacally when I saw this, but why does it hit so close to home? And I'll say one, it tends to ignore the context. Two, it over emphasizes individual responsibility. And three, it proposes a totally irrelevant intervention. So here's a quote from a resident explaining why this selling of resilience in self-care is so painful to people. So it's a issue of pull yourself up by the bootstraps. I hate it because it points the finger back at the resident, offering opportunities for self-improvement is fine, but look at what makes our life hard when we're working. All right. And what are these irrelevant interventions? So when we traveled with second, we took a multidisciplinary team that had a psychologist, a psychiatrist, and multiple PhD-level researchers. And they were so surprised and baffled by how surgeons everywhere were so disdainful of wellness. They were like, why not surgeons want to be happy? Why not? They want to be for those that work. And it's a good question. And I think it's because the problem is most programs put tons of resources into gyms and yoga, and that misses the mark, and it makes people more cynical. So, oh, I just froze it. A couple of examples that we observed as we went around to these programs. One program identified a free, a yoga instructor to do free yoga for them on Wednesdays at 7 p.m. And this didn't work for all the reasons you might imagine it didn't work. Not everybody likes yoga. Never anyone wants to do that at 7 p.m. on Wednesday. They have other priorities. They might want to go home and have dinner with their family. They might want to read for tomorrow's cases. They might have laundry to do. But still, why didn't this work? You think wasn't it better than no for yoga? And it's because of this. Everyone got emails like, why aren't people going to yoga? Which puts the burden on the resident? Why aren't you helping your wellness by going to yoga? Do we need a yoga champion? So we can go to yoga. So it's sort of that shame and that individual responsibility that blaming for not going to in the relevance intervention, that really derailed this. And actually after that, every intervention that was built as wellness that the program had no direction. A second failure was a lecture series on wellness. And I'll acknowledge that this is a lot of work. So for a program leadership to put together a curriculum, identify speakers, protect the time, that's a huge investment. And yet it flops. And as this program director said, it turns out that because of the sickness, weren't being matched. They didn't really feel like having another 16-minute facilitated discussion about wellness. People wanted lockers. They wanted better call rooms. They wanted meal tickets for when they're on call. And until that was satisfied, we couldn't have more abstract discussions about things that are peripheral to wellness. So second lesson learned, we tell people to consider context and relevance, including meet people where they are. So this, you might recognize as Maslow's hierarchy of needs. And so if you have residents who are at still at physiologic and safety needs, like, what are they going to eat and where are they going to put their stuff so it doesn't get stolen, then they can't really get up to self-actualization yet. It's not time for the lecture series yet. Both of these stories tell us that wellness is self-defined. And so you need multiple options because everybody is different. And it also can't be a checkbox. So it's important for the residents to have a voice because otherwise they just perceive it as people telling them something. It can be onerous. They don't have buy-in. They don't have ownership. All right. And I'll say there's a reason a lot of places emphasize self-care and resilience is because it's easier than changing the system. But as these couple quotes say, it doesn't have to be hard. What residents need is to think that people are investing in their well-being, and that doesn't really cost anything. This one program put in this once a month team and individual training. It sort of works as a coaching and as a bonding experience. And it's a once-some-of-the-experience. And it's made a huge difference in how they relate to each other. So small investments can have huge impact. So what is that context or system that people should be thinking about? And we developed this conceptual model in reviewing the multiple conceptual models for physician wellness that are out there, as well as our own qualitative data. And as I walk through each domain, you'll see pop-up will be asked about on the outside survey. So there's the domain efficiency and resources, which includes support staff, program coordinators, and protected educational time. There's faculty engagement, meaning and work, resident camaraderie, program culture and values, work life integration, workload and job demands, and mistreatment. And these are all components of the environment that are then filtered through the individual. So they're sensitive, they're crit or individual resilience to produce where they lie on the well-being versus burnout spectrum. And we did a confirmatory factor analysis, which showed that these things do hang together as individual domains, as well as regression, to show that they're all independently associated with burnout. And there is considerably program level variations. You see, particularly with mistreatment, there are places all the way as 0% of residents reporting some in some over 90%. So again, borrowing from quality and safety. That's why the first piece of our intervention, is just a report of data. So we take the absolute responses. We aggregate them at the level of the program, and then we benchmark them against other programs in the country. So you can see this program compared to all programs in the country. And the left column has problems with thoughts of attrition and feeling appreciated by their co-resonance, for example. Just to drive home this point about variation, I'll show you the three Harvard General Surgery programs in 2019. So there's this one, that's all green. There's this one, that's kind of in the middle, and then the third one, which is basically all red. So you might have some thoughts of which is which, but I'm not going to tell you. Oh, but what would you do if you were the program director and you were the all red one? I've now talked a bunch of different program directors about what they have done. So your options put it in a drawer to come back later. Be, quietly start to change things, but don't advertise it because you don't want to demoralize everyone. See, show it to the residents, D, show it to the faculty, D, show it to everybody. You guys want to do the pull everywhere? You can also shout it out. You can also do the pull. Is it work? You guys connecting? Oh, this is what I would say too. So I think actually this program did be. So every time I talk about residents in this program, they were very surprised to hear there was any such data available. Oh, some people put B. Does anyone want to say why they would put B? Was the person who said B program leadership? If he's shaken, is that no? Okay. All right. So I think the program did be. But I would say that you guys are right. I think radical transparency builds trust. And most programs, in most programs and most residents that I talk to you on these grand rounds, they say like they're not demoralized. They know because they wrote the survey. And in fact, having the data shared with them makes them feel that they were heard. So we tell people to show the data and then to ask what it means as well as what to do. So as this program director says, my residents are phenomenally talented. Part of the reason I think our program is really effective is as we tried to empower them. And finally, provide updates. And this is when I learned from personal experience in Requestor and we put something in place and it would be slow moving. And residents would think we just like gave off on it. But actually it was happening. It was moving through the administrative channels. So we just had to send weekly updates about this is this week, this one thing happened. We filled out this thing and it's gone off. This picture on the right is Ken Azaro giving a grand round that OHSU, while we were there, in which he displays all his employee engagement data to the entire department and they talk about what it means. So we have seen that at other places. All right. So the second part of the intervention is access to a wellness toolkit. And this is built of interventions that we saw at other programs as we were traveling. Currently has 66 in that website and 28 more are in the works. It's meant to be, it's meant to correlate with the report. So if you have problem with faculty engagement, you would click on this orange hexagon in the toolkit and it would give you all these different interventions that you could do directed at that domain. So just to show you an example, this is the holistic application review. It includes stuff by step instructions for how to launch this, including the bias calculator for reviewing application, reviewing letters of recommendation. The AMC best practices for conducting residency program interviews, the diversity engagement survey from the AMC. And I think most hopefully it has the application review form that Penn uses now that they have taken down their score requirements. And it just helps make concrete what it is people are looking at now that they have, they're starting to look more holistically. Each intervention is a coach for this one is Carrie Arons, he was the PD at Penn when this was implemented. And they lead webinars for us in which they log on with multiple PDs and they explain their intervention and they get Q&A about how exactly to do it. So far we've done 25 of these, they're about quarterly, there have been 330 attendees from 77 unique institutions, they're about 106 in the intervention trials. So this is actually most programs participating to some degree. We also have working groups for some of the more complicated interventions so people can crowdsource information in real time. We send out newsletters, we do virtual and in-person conferences and I do one-on-one office hours with PDs to go over the reports and direct them to particular places. We're about to launch a dashboard that puts all the information in one place so people can see these are my problems, this is what I did and this is what I'm still missing. All right, I'm going to walk through one particular domain and it's the one that really explains why we're going into third trial. It's also the one that wasn't in any other conceptual models, although I don't think it's unique to surgery. So this is the reports for that domain. So that domain is mistreatment includes bullying, sexual harassment, and gender, and racial ethnic discrimination. And you'll see that there's a little bit less variation among the three programs here, they're all fairly red. So there's a lot of room, I think, to improve in surgery nationally. So first trial data going back to first trial, so that women who are more likely to endorse poor well-being on nine of 12 measures. And this was, Concordant, with multiple prior studies showing higher burnout in women. And so in 2018, we started asking about mistreatment on the website survey and we found that it was a really common experience with two thirds of women reporting sexual, I mean gender discrimination and about one in five reporting sexual harassment. Among all residents, about one in eight would report racial discrimination and about a third, verbal, and emotional abuse. So overall, almost half of all residents and 70% of women residents experienced one more or another of mistreatment. And just like in prior studies, we did find that there was a gender just crop in C in burnout with women reporting more, but actually after we controlled for the level of mistreatment that they had those gender disparities in burnout went away. So even though there had been a lot of noise about can women hack it? Is it a problem of women or are we taking so many women in a paper out faster? It really doesn't look like it's the women. It's the environments we exposed them to. One of the criticisms of that paper was that we didn't define mistreatment. So how do we know that people know they're being mistreated? And I had a lot of misgivings about that whole line of thought, but to respond, we started asking about very specific defined behavior since 2019. And so we did, for example, the short negative act questionnaire looking at bullying. And we found actually that mistreatment rates go up when you provide definitions. So 43% of residents report occasional bullying. Whoops, sorry. And it tends to be more common for women and for people who are racially or ethnically minoritized. We also did this study about gender discrimination in sexual harassment and residence. And again, once you give people definitions for the treatment they're experiencing 80% of women and experienced gender discrimination and 42.5% sexual harassment. The specific behaviors we ask about are in the middle panels. You see there are range from unwanted physical sexual attention to being mistaken to a non-position. And you see associated factors on the right. So some of the more common explanations or hypotheses for these findings that are here, maybe women are worse performers than that's why they perceive more mistreatment, but actually you notice that you're more likely to report discrimination if you have a low abscess score and your male versus high abscess scores and females. So the hypothesis is true, but not actually for women. All right, we also publish the paper looking at racial elastic discrimination and 41% of non-white residents experience that including 71% of black, 46% of non-white Hispanic, and 46% of Asian residents. Again, you can see the specific behaviors in the middle panel. And again, you see that it impacts their wellness. And then finally, we did a study looking at LGBTQ plus identifying residents and they experience more frequently every type of mistreatment compared to their non-LGBTQ peers. Unfortunately, in this population, the attendings are the most common source. These residents are just as likely to be satisfied with their decisions to be surgeons, but they're more likely to think about leaving and more likely to consider suicide, which goes away after you control for their mistreatment. So, criticisms of that study are perhaps there's still misperceiving individual behaviors. So we started moving towards measuring individual perspectives. So I started working with Nicole Stevens. She is a social cultural psychologist that works at the Business School at Northwestern, who specializes in DEI in organizations. And so she has, so she sent these questions from the psych literature that measure beliefs that are concordant with DEI. So the first one is it's important for me to hear multiple perspectives in my program. And I think, promisingly, very few people answered incorrectly on this question. Most people understand the value of multiculturalism versus the opposite would be colorblindism. Similarly, before judging a co-resident, I try to imagine how I'd feel in their place. So most people did endorse empathy, which is again, promising. Although there were some slight gender and racial differences. And then finally, and I thought this one is the most interesting, if I'm sure I'm right about something, I don't waste much time listening to other people's arguments. So for more people endorsed this statement. And I think there's something about surgical training that makes us like have that horrific, right? We're trying to move quickly. We're trying to, I remember when I was here as a resident, you guys would give out that book, which had the rules in the front page. And one of the rules is don't argue with idiots. And I actually still use that one this day. I still think about that a lot. But when this question came up, I really was like, hi, wonder if I've been trained to not listen to other people's arguments. And it's just an interesting thing about whether or not that predisposes us to not accepting others' perspectives. All right. The other thing I was interested in is whether people were aware that there were inequities at their own programs. So we've asked these questions, which are sort of the first three are about fairness. So do you perceive fairness in your program? So residents is the level playing field. Opportunities are just to do in a fair way. And residents have equal opportunities to network, or social engage with faculty. And most people did actually feel that these were true. However, there were some gender and racial disparities with women feeling being less likely to feel these were true and same for black residents. And to some extent, Asian and Hispanic residents. The last question, applicant identity background should be considered when ranking medical students to match. So this one actually kind of surprised me. Almost half of residents said no. I thought we were, I thought that was a pretty well-accepted metric for both medical school and residency. So I was pretty shocked to see that. But we're thinking about how to what to do about this next. So these things will inform the third trial Transformering Health, the inclusion and residency diversity, which will launch this summer. So there have been decades of data showing that physician diversification would reduce disparities in care. Yet between 2004, when the IOM put out this report, summarizing all this data. And 2018, when the American surgical put out a white paper, resummarizing the same data, the really hasn't been that much progress. This graph will show you cross-sectionally, like a career pathway on the x-axis. And then the percent of the underlying population on the y-axis. So you see that women make up 50% of the US population, about 50% of medical school graduates, 38% of applicants for general surgery, 41% of general surgery reasons, but only 27% of academic surgical faculty. And the green line is Hispanic residents. I mean people and black, the blue line is black people residents faculty. And you see the only line that goes up is white men. Because I have to 50% despite only being 40% of the population. And I think that lack of inclusion is driving this differential attrition at every level. So we focus a lot of attention on diversification efforts. But I think where we really have to move is retention efforts. So this quote really well crystallizes crystallizes well how lack of inclusion drives lack of diversity. This resident is talking about why she picked her program. When I interviewed, I thought they were intellectually serious and respected differences among each other and weren't very focused on one identity as a program. I wanted a place where people get research, where they wanted to research, they get a hobby they wanted to have. And people weren't all doing the same thing. They had families or they didn't, they like sports or they didn't just didn't seem like a place where you had to be a certain way to sit in. So organizational psychologists think about inclusion as both a sense of belonging and feeling valued for the ways in which you're unique. In second, I haven't really focused on this treatment as showing us that people don't feel that they don't belong. But I think I've been missing other piece that they also need to feel seen for who they are, seen and valued for who they are. So obviously you have neither you feel excluded. But I think many people in surgery are living on the edges of this with one or the other not but not both. So they may assimilate in order to belong but feel that they're not being authentic. They may be recognized for being different but not truly accepted. But organizational psychologists recognize that only with both can people fully engage and contribute in their organizations and only then can there be true organizational growth. So how are we doing in efforts? There was recently a systematic review and surgery looking at DEI efforts and the majority of them are on recruitment and not retention as I said. So their diversity efforts but not necessarily inclusion efforts. I think most of us have been through implicit bias training. I think every institution has some version of this right now. But unfortunately preliminary data in medicine shows there's no relationship between hours of training and explicit or implicit bias expression and residency. This is data from the change trial which includes multiple medical schools. Data from organizational psychology. More generally I show the implicit biases that associated behaviors are highly resistant to change. And in fact giving training may be counterproductive because it makes people feel validated in having biases and it also reduces perceptions of how harmful they are. The third thing I'd say people are doing is didactic around disparities. However I talk to a lot of program directors who are at under resource programs and they don't feel that they have the knowledge or resources in order to identify speakers to teach them about these issues. And there was recently a study in JAMA Surgery showing that 63 percent of surgeons don't believe that disparities exist even though they're very well documented. So it seems like our individual institution approach is probably not working. I think what we're missing is what organizational psychologists focus on. So organizational policies and practices. So organizational culture defined as shared and fundamental beliefs, normative values and related social practices both reflect and reinforce individual behaviors. So they lay the critical roundwork for inclusive behaviors. So rather than just focusing on how we can teach everyone to be better individually we need to incentivize them through the other pieces, the other hexagons you see here. So let me walk through an example. And this is research that I am doing with the other Dr. Rangel, maybe the primary Dr. Rangel to me. And so she studies parenthood I think is most of you know, motherhood and surgery. I would say that most surgeons have been trained or understand and recognize now that women are just making the same choices that men are to have children during residency. And they're just sort of we lost a lottery that we biologically have different things to take on. Those that don't get it I would say probably know that they're not supposed to say so. So I think we've reached a plateau in individual skills to leave some behaviors. We have made some progress in policies which is remarkable. The ABS has changed our parental leave policy to allow for more time and it is gender neutral now. Many individual institutions have implemented lactation policies. I think Dr. Kishman told me about new pump rooms that are being built in the new hours which is awesome. But yet in 2021 47% of women told us they were delaying pregnancy because of residency. So why? We have all these we have this infrastructure for them, right? We have policies that allow them to do it. Why don't they take it as accommodations? And I think the reason why is the other hexagons within the organization. So I don't feel that issue of your bad mom because you're working. I definitely feel the reverse of that. You're a bad worker because you're a mom. So how many times have we looked at a have we written me to a letter recommendation or received one which said this resident is so hardcore. They stay late every day, right? We really value presentism. And women see that, right? And so when it comes to choosing between choosing between staying late and going home and you don't have a choice about the going home you feel like you're a bad worker, right? And it's hard for you to compete with the people who don't have that competing interest. As this quote says, it honestly comes down to your partners and what your financial resources are. You can't really pay for a good daycare on a resident salary. So you're dependent either on your partner having a good enough job that they can pay for it or not working at all, right? So if we do value presentism then we need the infrastructure for people to do that. And I think most places don't have this. All right, finally, as this program director says 40 years ago, no one gives you as I was spending time with my kids. The way I was going to be a good husband is I was going to be a surgeon. And we haven't really restructured the training process to around the multividentities that we all wear. So we need more role models to normalize family as a priority. We need the infrastructure for people to participate in that way. And so we need to change metrics and rewards if we want to prioritize different outcomes. And only then would we have inclusion. All right, so for third, we will be similarly giving out data reports that has some of the data that I showed you. So again, about this treatment as well as individually expressed by us youth and beliefs. We would also collect real-time data versus via an app that's currently being put out by ASPASS. And we would co-laid these into a report. The other things we would put in are data from a leadership survey about their own priorities as well as an inventory of their policies and practices. Again, to try to match what they're doing with what their outcomes are. And then finally, we're planning to a centralized review of primary data, again, trying to get at something that is more objective than what people are reporting. So we're assessing, doing natural language processing of CCCC reviews for residents at every program, as well as getting faculty demographics and doing a network analysis of where they're moving over the years, which places are promoters or detractors. We would again build a toolkit this time of organizational psychology interventions. These are the four strategies that are purely based in the organizational psychology literature for eliminating individual bias. So I'll sort of quickly go through. The first one is intergroup contact. So having interactions with someone from an out group. Countering stereotypes is presenting people with representations of people who buck those stereotypes. For example, strong women. Perspective taking is actually what it says. Perspective taking is forcing people to empathize with the out groups perspective. And super word in that identity is creating a shared identity for both groups. So for example, identifying as Americans rather than Republicans or Democrats or surgeons rather than women or men. And some places have already started to do this. I don't know if you guys have heard of this. Cultural complications M&M. It's an intervention that's done at University of Michigan. Basically, within their M&M structure, they present a case of bias and then there's discussion. It is presented as a didactic curriculum. However, the reason I think this is powerful is because it does these three things. It has these cases, which engender tons of discussion. We've done this in our place. And I think just that view into other people's experiences, so enlightening. We've had multiple surgeons say I had no idea that my residents were experiencing this simply because it wasn't their own experience. So I think that is, it is a powerful thing that's worth doing. You guys have not yet. All right. I think what will be even better or more enlightening will be the organizational interventions that come from psychology. So some of these you will be familiar with. So diversifying opportunity. We thought a lot, as I said, about the set the recruitment level. So for example, US Emily scores are going away. And as one way to try to increase diversity in the applicant pool. But another way in which I don't think people are so thoughtful about is that we tend to sponsor people who remind us of us. And so I think that contributes to the differential attrition along the pathway. So if we can be more transparent about what the processes are when we decide who goes up from promotion or when we we show people what the opportunities are and how they should filter themselves for them. That will also diversify opportunity. The third is making evaluation more systematic. There are tons of interventions for this actually in the organizational psychology literature that we can bring here. So for example, we all do resident evaluations that have a like or type scale. And you tend to say like, I like this one so 88888, right? Or 8887 to look like I did something else 888. But in business, for example, you can't give a like or like scale without giving an actual example. And there are just different ways in which you can de-buy us different evaluation forms and give more objective data. All right. And the last is increasing accountability. So a lot of programs actually now have a vice chair of DEI. Although I'll say the roles I think are not so well defined, which we will work on. But just having some system of accountability, having goals and holding people accountable for them, I think will be really important. All right. So I'm toying with the idea of a minimum commitment. I'd be curious of what you think. So part of the reason second is so messy is people decided to engage or not. And we're now trying to sort out who did what. But should we tell people you have to do at least three things? You have to do at least one evaluation thing and one transparency thing. I guess the downside of that is that people who don't do what they want maybe less engage and not really do it, they might just be checking the box. All right. As I said, many places have been naming bysters of DEI. But from what I can tell, there's wide variation in what they're tasked with, like what the role is, whether they're resource, whether they truly have oversight of other processes that are going on in the department. So we would have a learning collaborative for those vice chairs. We'd provide them with coaching. But I think the most powerful thing would just let them would be letting them also down in the same room and share notes and sort of help each other through the process. Finally, we'd be providing centralized resources. So to get at that issue where multiple places have been trying to do not tactics that nobody really knows what they're doing, we would create one national grand round series that would go through structural racism and provide high level speakers and data to provide a baseline of education. A second would be providing community. So we had some data showing that non-might or Hispanic residents were less likely to report a mentor who genuinely cares about them in their career. That was second trial data. So in response, we partnered with the AAS to develop a national mentorship network. So we asked residents from our intervention programs to sign up. And then we matched them to mentors at other institutions. There were 151 pairs, 98% of which belonged to a minor time identity. And in the preliminary data after a year of running at 97 reported that their mentors gave them on-site advice, 60% for 4% fell to motionally supported. And interestingly, I didn't even anticipate those 58% reported that they got opportunities that they wouldn't otherwise have gotten. So they came from solar programs. They got the book chapters or peepers with their mentors and really felt like they had been elevated, which is again, something I didn't even anticipate, but it was awesome. All right, so what we would do for third is expand this. So there would be peer groups for some support. And I think we might do some social belonging interventions from psychology on those groups. There would be faculty networks. And then those two things would form mentorship families. So again, to extend the networking. And we could provide them resources as well. Training on how to do this and more structure. Okay, the last centralized resource is based on this data. This is ACGME data that shows differential dismissal rates by race. And you'll see for surgery, and it's pretty small, sorry. For surgery, there's a sixfold increase in dismissal rates between black and white residents. And it's actually similar for all of the fields. For anesthesiology, it's like 12-fold for medicine. It's our pediatrics. It's sixfold again. And we've heard from multiple residents, faculty all over the country that what happens is that these residents get identified early and can never dig themselves out of that hole. And so what we've started to do in an informal way that we would subsequently formalize is get referrals from program directors, self-alformals from residents. We would conduct an independent assessment and develop recommendations around remediation pathway and provide more meaningful remediation than individual programs, perhaps are able to do depending on the program. We would provide external mentorship teams for each one of these residents. We have one right now, actually, to advise them on whatever came out of that independent assessment review. This is based on work that's been done for the last decade by Bonnie Mason. She's now the director of DEI BCS. She's an orthopedist. And so she has the ornate pod. She has this council for surgical residents. Essentially does this for a cohort of orthopedic residents. So we'd be expanding for general surgery. All right. Next question. Let me activate this poll. What are we missing? Will that work? Okay, I have to activate. Oh, I think it did. I think it's just a free text. You've been put in what you think. Are these are actual issues with DEI and surgery? I got some stuff on the chat. Oh, it's see me. Hi, Blind. Organizational, by and. Earlier, interest. Who types that? What does that mean? Is that pipeline? Right. I agree. I think the that's why I think the inclusion thesis is the issue because if it was just a diversity issue, we should just be able to get people in the door and they should fly. Oh, I'm missing. Faculty understand the needs. Lots of unspoken culture that are difficult to learn. Yeah, I think that in the couple of students we've been mentoring, not students residents. We've been mentoring now. That has been really eye-opening for me. Probably lesser for the rest of my team. But yeah, just the idea in which we we learn all these things, these ways in which to behave. And if nobody tells you, you have no idea. Right. So one of my residents was telling me that she was in the or with someone and they basically said stop. Stop asking for instruments. Right. And so then she responded to that feedback by not being proactive within the surgery and everyone else thought she was not preparing for cases. And if you were to listen to every piece of feedback and like constantly swing back and forth between the things different people say, you can see how you very easily fall out of that. Followed a favor, right. Like one inappropriate piece of feedback then results in behavior that tanks you for the rest of the year. All right. What else is here? Leadership buy-in resources. Good data. I have to say like for a second, we're I mean for third, we're talking about notched randomizing and just making it single arm because I think or I hope, participle helpless is pure pressure. Just everyone else is doing this thing. I have to do this thing. But I don't know. What do you guys think about how to incentivize leaders? Quite a bunch. Okay. Here we'll go to the next section because what time is it? Yeah, we got 15 minutes. All right. So the next thing I'll talk about. So third actually has three two parts. One is about diversity and equity inclusion and the other is about faculty well-being. So this is one of the common thing I heard when we were traveling. The work needs to be done. Usually the attendings have the largest capacity to absorb what's offloaded from other people. There's a certain amount of burnout and a certain amount of unwellness that exists and like energy can be neither created nor destroyed. I think it'll be shifted to another provider. You'll see a spike in attending position among this. So there are a lot of people who are worried that resident wellness would result in attending unwellness and do those things really compete. So here's my question for you. Oh, I forgot to delete this. The high is me. You can ignore that. What's one thing that would make your work in life better as faculty? I'd like to activate it. Hang on. Oh, now. Is it working for you guys? I can't read it fast enough. Social connections. Prioritize flexibility emphasis. Does anyone want to explain any of those? Yeah, I agree. I'm going to show you something about that. I like the cricket. Thanks. All right. Mental needs. Kiers. I think it's sort of getting at what you're saying as well. All right. Fellowship. What does that mean? Oh, maybe that means relations as well. Or do you mean the actual fellowship? That person's in the room. Okay. So let me keep going. All right. So we'll be looking at, we'll be surveying faculty now as well as residents and doing something similar for faculty. And the conceptual model that I think we're going to use is this one from this heart span and group and article in the New England Journal. And it's much simpler than mine, but it's the one I wish we had thought of because it's much cleaner. Three things matter for intrinsic motivation positions, competence, relatedness, and autonomy. And I'll go through them quickly. Okay. So competence, we all need to feel that our work is meaningful, that we're good at it, and that we're growing. But I would say just like the other two trials that it is the organization that helps us feel that way. So having efficiency and resources and support a organization in order to do the things you do well is what we're going to be measuring. So what I would hypothesize that is that organizational efficiency or lack thereof is the context that many places are ignoring when they're throwing us the pizza parties. As this surgeon says, somewhere along the way, the administrators figured out the whole goal of the operation should be to expedite and facilitate surgery. You would never want to tell patient you can't have surgery tomorrow because there's some enough beds. People aren't going to beat their heads against a wall in that system. And as a result, there's extraordinarily low turnover within their system. And the second is that cultures that promote shared coping and immunize shame and blame foster growth mindset. So we, um, so we talked to multiple people about complications and what that means for, um, for their well-being. So everyone who takes cares about this job and cares about what they do is going to take complications to heart. We heard this over and over again. And yet, when people described M&M, many people use this analogy of predatory animals. Blood in the water and sharks would come at you, and you knew you're just going down and you would just take it. We observed 15 M&Ms because we went around these programs and looked at them and 12 of them talked about blame. They blamed residents and fellows, other medical and surgical specialties, nursing, sometimes the patient. Only one program ever talked about coping in all those times. To our credit, it was about a pediatric patient, but I think there's a really under leveraged opportunity there. We have, we have this situation that we know we're all in. We are bound to have complications and take them to heart. And, uh, there is a way that we can co-support one another throughout, which brings me to relatedness. So, as you said, collegiality and belonging and uniqueness, as I said before, as well as having a shared mission. And I began to say that organizations kind of line incentives to further these things through servant leadership and recognizing and appreciating people for who they are. So, um, so we talked so much about the business of medicine in these interviews with faculty. I have resident presenting about some of these in a couple months, but as a preview, there is two, uh, there's a couple different models, obviously. There's probably as many models as their institutions, but here are some comments about two. Um, so this chair was talking about a prior practice. He had a partner and he would try to help her. She had four nannies or hasn't his fellow, but she would be like, no, no, no, no, those are my reviews don't touch them. And that's the behavior because everyone is just trying to get our views. It was really toxic. Second, this chair said, we just redesigned our comp plan. In the division model that they have a divisional RBU target, and I predict that people are going to be much happier than people with individual targets because they're not competing. I have another division who have five different values per worker, you based on practice, and it's still a collections based model more or less, and that's the group that competes the most to, the most unhappy. Um, so I am curious to find out, uh, to Candace, sort of all the models and figure out analytically which ones are the ones that support people the most. I actually think that unlike that other surgeon who thinks that we just spread the well, we just spread on wellness around or we transfer to other people that emotions and burn out are contagious. And actually, there's some data for this and they're organizational, not even the organizational, the psychology literature. Um, all right. Third thing is autonomy. So we define that as individual control over your work product, your scheduling, your processes. Um, and I would say that this reflects the organization's respect for us as, uh, people who can make responsible decisions. I think somebody said flexibility. So giving us the flexibility to make that decision and being responsive to our feedback. Um, one of the main questions here I think is interesting is what's an FTE? So how many are views is that? What else, you know, what else is in your protected time and how do the people protect it? So that'll be one of the things we'll be trying to figure out by looking at national level data about what people are doing. Um, I actually think, uh, it's how I check out the quote, this is why this probably doesn't make sense. But, um, one of the common misconceptions I hear about wellness is if people are really well, they will not, it will, they will not be very well trained. But nobody thinks that's true for faculty, right? None of us think if I were happier, I'd be so much less productive, right? In fact, in, uh, the econ world, happy people are much more productive by 12%. Um, so I'd love to quantify that for us. Um, if I have people who, this chair says analogously, if I have people who are happy who like being here, they actually work harder. I feel like they'd do anything I asked, even expense to themselves because they felt this way. Um, she was actually talking about residents, but I think probably the same is true for all of us, right? We're all sort of intrinsically motivated, um, and that becomes self-sustaining. I think there's also, there's probably a deflection point in that curve though, right? Like, um, there's such a thing as too much. So as this one faculty member says, um, the finances have changed. People are expected to work all the time to generate our views and income. And it's hard to bounce that you're just physically unable to keep up. And doctors were driven by guilt and responsibility and ethical obligations when your boss acts to be on a committee or trying to publish a paper and then the patient's sick and you go to operating her own somehow, you do it all night, you stay up all night and you write the paper. So yeah, there probably is a, there's a maximum benefit plateau. The other thing I think we're going to find is that financial incentives are not really what's giving people meaning. Um, so here's some more quotes about our views, the issue of our views where you're given a target and you're constantly checking check boxes, you feel like you're constantly feeling in some way it's really demoralizing or this faculty member, a long a lot, go lost my love at this job because it's become about making money for the hospital instead of that patient care. I think there are other ways the institutions are able to appreciate people for their work they do, but it's not entirely clear what those are yet, right? Right now, like the way institutions communicate love is through salary. And I think that's probably not the answer for happiness. Um, so I'm curious what you all think about those two things that are launching this summer. Like, do we have, are we headed in the right direction or those the right ideas since we have the smartest people in the country or the world in this room? I'd love some feedback. I'll say we run all these projects with a massive team. So we have residents from all over the country that come in. If you are a resident interested in doing research with us, email me. We couldn't do it without them. We also have a massive team just to run second between PhD statisticians, qualitative researchers. We also have a bunch of collaborators in different fields. So as we've progressed second as expanded. So there's a vascular armistice and there's a CT arm starting up. And we just started a Canadian arm a couple weeks ago, which has been very interesting. We have totally different issues. Some the same, not totally different. All right, again, I am super gratified to be here. Thank you very much for having me and for the lovely dinner last night. I would love to get your feedback and I'll take any questions as well. That was just a tremendous talk. With the M&M slide with the blame, it's usually anesthesia's fault. John, so I'm surprised that they didn't make that list at all. But in all seriousness, a ton of data, a lot of insight. We have about eight minutes for questions. We acknowledge as well, we had over 100 folks on the Zoom at the peak. And I know we have three questions, but I know there are going to be many other questions in the audience. We'll start with Terry. All right, I'm sorry. Go ahead, John. We'll have Terry go next. I just had a quick question about the bullying. Yeah. So bullying has existed for a long time. And so I'm wondering if it's increasing, is that why we're seeing more burnout? What do you think about that? I don't know if it's increasing, because I only have five years of measurement. You mean over the course of decades? Yeah, I think it's existed forever. Yeah, so it's hard for me to comment about before, since I don't have, like, from a scientific perspective, because I don't have that data. What I am hearing is that this treatment is increasing from patients. It's probably stable from faculty or G-creening, but patients have become a little more bold. I think over the course of the pandemic, I don't know that I can explain why that happens. But more and more institutions are trying to figure out ways of dealing with it. You're talking about faculty bullying, though, huh? Traini's faculty. Yeah. I think, I don't know that it's increasing, I guess, is what I'd say. I think that is contributing to burn out though. Do you think it's increasing? I'm not sure. And I don't know how much personal responsibility we should have regarding this issue. I know you talked about this at the beginning, but I think if you're not sleeping, if you're not getting outside with nature, you're more likely to get burnt out, right? And so I think we do have some personal responsibilities. Yes, my point isn't that we don't have personal responsibility. My point is that we currently place all the responsibility on the individual, but I think it's both. I agree. Thank you for the great talk. Thank you. Thank you so much for enlightening us. I'm sure a lot of the points resonate with so many people, but a lot of the points are so new. And I personally am really grateful that through our absolute organization that you're a real leader in our wellness committee. And I thank you for that. So my question is, I have heard kind of through the great line. Could you update us on how wellness metrics are now impacting residency and program evaluations? Because I've heard they're starting to be integrated. Yeah. So the ECGME separately measures wellness. And they do so not as part of accreditation. So there is the wellness piece of their survey. It's out right now, right? I don't think they've closed Africa. So when we all get our survey from the ECGME, it has like the part with the stuff they need for accreditation about hours and supervision and whatever. And then there's another piece about wellness, but that data doesn't get fed back to the RCs. They don't use it for accreditation. That's just supposed to be for you as a program to reflect that said we've used we've had that data from them and analyzed it because we were interested in whether or not there was a correlation between resident and faculty well-being because we kept hearing about trickle down. And there was not. And I actually don't know if that's because there is no trickle down or because nobody wants to tell the ECGME that they're not unwell. And so what we're moving to is a different survey mechanism in which we are a third party vendor. So the ECGME will partner with us. They will give us access to all the faculty in the residence, but we don't feed the data back to them. And the idea is again so that programs can use that to improve without having that fear of accreditation. We're in the middle of like contracting for that right now, but that's broad strokes what's going to happen. I think what we've I'm like trying to remember we're on the same committee with Mary Brandt. I'm also on another committee with Mary Brandt. That's why I'm confused. With the ECS and part of what we'd like to do there is if we're able to measure wellness at an institutional level connect it to outcomes on the quality side and then provide that feedback to programs that are in that sense not general surgery programs, but departments of surgery that participate in their quality activities. Wait, why don't we see I know there's four in the chat or Q&A's and see if we can react to those. I keep cooking it, but it doesn't want to oh maybe because I moved it down here. So amazing talk. Thank you for providing data for something that was just a feeling for so long. Where are the tools to retain diverse trainees when the faculty are not diverse yet? Is anyone studying this at a level of faculty? A lot of the same issues, but without advocates and how do you study this problem in small groups and maintain an on me? So I'll go ahead and let you tackle each one of those. Okay, tools to retain diverse trainees. I think so some of them I showed you the four strategies for individual level bias and the four strategy for organizational level bias and what we're going to do over the next year is really blow out and hammer out the details for each one of these. It's probably more than I can answer a five minute thing, but basically changing organizational structures I think is going to be the key one as well as providing individual level education. All right, is anyone studying this a level of faculty? So yes, you might have sent this question I think before I presented about faculty, but yeah, the idea would be to study both wellness and DEI, both the resident and the faculty level. So this becomes a department level activity and no longer a residency program level one. And then three, how do you study this problem in small groups? Yeah, this is a super good question. One of the things that we did in order to maintain anonymity is you don't get data back unless you have a high response rate and you have to have at least four people in the denominator for each question. So if you have fewer than four women, you wouldn't get gender discrimination data back because it's too easy to say like, well, I know you and you said this and why are you making this look bad? Even though our data comes with no stick, like there's no lots of accreditation, there's nothing they get other than an ugly report. People still sometimes read it as, why did my program, why did my residents tell an external person something bad about my program? And that's sort of like this vicious cycle of feeling silenced in order to look good. And so we try to talk people out of that cycle, but one of the ways we protect the residents is not giving the data back unless there's a certain number of respondents. I think what we'll do in the future because we are moving to studying things that are currently all small groups is aggregating data. So for example, if you're in a small program with less than four residents, we give you data for all the programs with less than four residents because perhaps you just shared issues. Okay, well, thank you. We're after the hour. So I think if there are any more questions, we'll have to come up to the podium and talk with Dr. Who, otherwise thanks for a tremendous talk and for making the trip out here. A lot of insightful data to think about and a lot of changes in the future. So thanks again. Thank you for having me. Hi, here I'll come down. My dad is here. He's at the moment. He's here. I was just talking to him. Oh, that's the hard thing. I'm sorry. I was in a long time. That's good. I'm having a bell in the middle of the morning. That is good. That is good. So I'm going to have to get started. I'm going to have to get a little music today. I'm going to have to start at 7.8. So I'm going to have to get started. So I'm going to have to get started. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Yeah. Thank you. Thank you. Thank you. Thank you. I'd like to move up the floor. Yeah. Please, I can't go up the floor. I can't go up the floor. Please, I can't. see a cocoon or to last 15 seconds and path my podcast DESTINUERS More videos of also favoriteYouTuber you you you you you you