Dr. Mary L. Brandt - Beyond Wellness to Joy - A New Paradigm for Medicine

Thank you, Catherine. It's a quick one record. Okay, Jamie should go. Perfect. So good morning, everyone. I am Jamie Robinson and I'd like to welcome you all to our surgical graham rounds today. I apologize. This morning we have the pleasure of having an invited speaker, I guess, join us. She has been chosen and invited by the senior fellows this year, myself and Dr. Danielle Cameron. And she graciously accepted to join us despite her very busy schedule for which we are exceedingly thankful. I have the privilege of introducing her today. She is a true leader in pediatric surgery, Dr. Mary Brandt. Dr. Brandt is joining us via Zoom this morning from Children's Hospital of New Orleans, where she is professor of surgery at Tulane University School of Medicine. Dr. Brandt completed medical school and general surgery residency at Baylor College of Medicine, followed by a fellowship in pediatric surgery at the University of Montreal, St. Just Seen. She returned to join the faculty at Baylor College of Medicine, where she holds a very distinguished record of accomplishment. In her time there, she served as senior associate dean of student affairs, associate dean of medical education, and program director of general surgery. She is now distinguished emeritus professor of surgery, pediatric and medical ethics at Baylor. Dr. Brandt achievements do not stop at that. She has not stopped striving for her own education and knowledge when she reached emeritus professor, as one of her most recent accomplishments is completion of a master's in divinity just this past year. Her clinical expertise and leadership include areas that vary atric surgery, in erectile malformations, biliary, chisia, and childhood liver disease. As we all know, Dr. Brandt is nationally known for her significant contributions to clinical pediatric surgery. Arguably, however, the most impressive achievements on her CV that I was very graciously allowed to review are her innumerable honors and awards for her impressive education as students, residents, fellows, and her contributions to ethics, humanism, and others in medicine and surgery. So we are honored for her to join us today to talk about something that we should all focus more on wellness and burnout in surgery. So thank you very much, Dr. Brandt, for joining us this morning. We could be sad that you're not here with us in person, but we're very glad for your time. Well, thank you so much and what an honor and thank you so much for that introduction. So I was actually born in Boston. I was telling Dr. Fisherman earlier, and so I am so sad I'm not able to get back for a good lobster and some beverages with a lot of old friends, new friends, and friends I haven't met yet. So I have asked for a range hack for that gathering. And so hopefully that will happen sometime. So today's talk. I have kind of retitled beyond wellness to join, and I want to talk to you about a different way of thinking about something that we've all been focused on for a lot of years, and kind of walk you through my thinking about it and maybe give you a new paradigm and a toolkit, some suggestions for for yourself and perhaps institution. I want to acknowledge first of all that we are gathered today by the miracle of zoom on the ancestral lands of the Chinamaka Massachusetts and protected peoples. Not talking about cardiac physiology, but I do want to bring up a couple of really interesting medical models that have helped me think a lot about how about wellness and burnout and this whole epidemic that we're in in surgery. And the first is the startling curve and we all understand that you put more stress on the cardiac muscle and it produces more until it doesn't. And this is actually from a manual on training elite athletes. And so the same thing is true. We can perform and I'm not talking about productivity. I'm talking about performance here. Well with increasing stress until we don't. And we also understand this in kind of a different paradigm is physicians because we know that most of the time we live in a comfort zone until we have an illness or injury and we start moving down a spectrum. Hopefully that we get rescued from our by our physicians into illness. But it we really don't want to just stay in health in a comfort zone. What we really want is human beings is the other end of that spectrum true wellness in the green zone. And when I think about that in terms of a career and burnout and all this these things that we're contemplating in medicine. I think well being is in the comfort zone of our career and what we're really striving for and we don't talk about enough is joy. So you heard I have a fairly traditional academic surgical career. I did not start off my career thinking I was going to end up talking about this and being a part of this. But as you heard I also had a good part of my career in educational leadership and as a program director and as a dean of student affairs and as a mentor to colleagues and friends. It's been very, very clear to me for a lot of years that we really do have a growing problem of burnout. And then when I went to the institutional people around me and said let's do something about this. What we got was yoga classes and pizzas sent to people and then my absolute favorite in the straw that wrote the candles back were the mandatory wellness trainings and resilience trainings. And you just wanted to say what what is the disconnect here because there's there's something very wrong going on and this is how we're treating it. You have a liberal arts background and as you've heard I've gone back to that liberal arts background with a new degree. But when I sort of think about burnout and burning and inflammation, I began to real think might think a little differently about this. First of all, I hated the word burnout forever. It sounds like an individual failure. But the root of that word flame and burning maybe does help us because where I am now in thinking about this is my definition of burnout. Is it is the end stage manifestation of physical emotional and or spiritual inflammation that can be caused by a variety of insults. And that may ring true and make you think of something else because it certainly did me. And that's when I began to ask the question what if burnout is actually more like sears and the spectrum of sears and subsets that we deal with clinically on a regular basis. What if the end stage of burnout is actually caused by a variety of things. You know, we're trying to fix one thing like cost schedules, but it's really a whole variety of things. And what are those things then. So the first bucket I put realized was insufficient self care and you'll notice the letters and little circle are the smallest on this chart. Because I don't we all know what to do. So yes, there is an issue with self care and I'm going to talk about it a little bit, but that's not the answer. So what are the other two really big buckets that contribute to this problem. The first I think is a failure to recover from injury. And the second and probably the most important is severe or persistent moral injury. And that can be personal, societal or institutional. So I'm going to talk about those three buckets and let's start with the inadequate self care. So when we talk about self care, there's really four areas we're going to talk about and I this is not going to be a lecture about eating, exercising, sleeping and preventive care. I'm going to give you a couple little key points that I think are important. And the first is diet and as much as we harp on this, I cannot stress enough how important this is. And the toolkit here is really what you have done for your entire life in terms of planning your studying and planning your work. You need to do this for yourself. You need to plan your meals at work, especially if long days on call, which means cooking or learning to cook most of the time. Don't make that be a hard stop though. Part of planning is it's for a week at a time and you have to shop for that week at a time. And at a minimum, promise me and promise yourself that you're going to try to get fruits and vegetables at every meal and you're going to try to cut out fast food. Now, it is a craving when you've been on call and have not planned to want those carbs and want all that comfort food and I get it. But the only way around that and again, this is not cooking, right? Making a to go thing by planning with good food like that actually does taste better and makes you feel better on call. So think about how you're planning what you eat. And everyone says, well, I don't have enough time for this. I point out to everyone that there is exactly the same amount of time every single day. This is not the time management problem. It's a priority management problem. And the same is true for exercise. Currently, the recommendations for health well established and well studied is 150 minutes of moderate intensity aerobic activity. It doesn't mean 150 minutes at one time. It can be five minutes here and there, but this is getting out of breath. That's all that means we're also supposed to be lifting weights twice a week or doing some kind of resistance training. And for the musculoskeletal injuries that I'll talk about in a minute, this is probably the single most important thing we can do for our own well being our physical well being. And what we do will this survey of surgeons showed that cardiac cardio cardio exercise about half of us meet the criteria. And for the strength, it's about a third of us. So we you're in good company, if you're not doing it, but really again, it's priority management and this should be a high priority. How do you do this? Same way. Make a plan for a week. If we plan to work out two or three times a week, we end up working out zero or one. So you plan for every day and then you're a little flexible so that it'll happen three or four times a week. It's important. This isn't a scut job or to do list that you need to go play. It needs to be fun and you need to look forward to it. Whatever that exercise is. But the key is accumulating it during the week and that's we love toys. We love technology. So put it on your Apple Watch, figure out what the app is that you need and get in those 150 minutes. I have a treadmill desk in my office. It is not that fancy. This is a super expensive radiology one sold at a convention. But it but it since we spent so much time at a computer, it's not a bad way to accumulate some minutes of fast walking. And then the best hit training in the world is climbing stairs. So take those two or three flights of stairs, get shorter breath at the top. It counts. But sleep is another super high priority. All of us think we can get by with less sleep than we need. And it's just not true. It's physiology. We all need eight hours a night. It's seven to nine. It's a range. But it's not four or five friends. So you're kidding yourself. If you're getting less sleep than that and you think you're getting by. And it's important. It's important for not only our own health but for our patients. So currently 60% of surgeons report an average of less than six hours of sleep per night. But importantly, even more importantly for our patients, if you're awake for 17 hours and there are you do functional tests like they do for someone who's been drinking 17 hours awake is the equivalent of legal intoxication, a blood alcohol level of 0.05. And 21 hours a week is a really long night at the bar 0.08. And finally, the last point on self care for our physical being is our own routine medical care. We're bad at this too. So if you look at the data, we're normal human beings. We have health issues. The graph, the black is in 30s, 40s and 50s. So we're just like all human beings. We gather more health issues as we age. But we do really badly at it. We don't do our screening colonoscopies. Cardiac exams testing for prostate and breast cancer. So it's embarrassing as a physician. If you get diagnosed with something you could have screened for. So it's very important that we develop a relationship with our own doctor that we when we're healthy that we actually have someone we can go to and call. And we don't ignore these agent appropriate screening tests or any symptoms that persist. Now, there's another part of self care that I do want to spend a little time on because it's so poorly taught and not well understood in surgery. And that's the ergonomics of our profession. So the field of ergonomics actually was developed in order to keep factory workers on the line. And it makes kind of makes sense. But the question then was what takes people off of the line in a factory. What kind of movements, what kind of work, what do we need to pay attention to. And it turns out that the three things in a factory worker that cause ergonomic injury. And it's awkward body postures frequent repetitive movements of the upper extremities and prolonged static head and back postures. Everyone's going, yep, that's surgery. It's not surprising then that it hurts to do surgery 50 to 85% of surgeons experience pain while operating if you took that to the longer cases it's 100% we all know that. 33% have taken breaks to relieve pain and a third even with severe pain work through it because that's what we were taught that's the culture right. I was taught that it's like working out that you get sore muscles is just part of the job. But this is one of my absolute key take home muscles messages, sorry, muscles. This is not muscular soreness. This is joint soreness. And therefore if you are experiencing pain while you're operating you are being injured. If you're taking notes write this one down pain equals injury. 40% of surgeons experienced true injury during their career. This can decrease your technical ability, but maybe more and on a personal note it ends your career early and it ends all the other things that are working. So there's a huge personal cost but there's also a cost of the institution of not paying attention to this. How common is it? Well this is office workers in the first column, fish factory workers in the second column and surgeons in the third. The economics actually looks at positions at work and categorize them as one is normal four is stop it right now because you're like getting so injured. But the ones that we're going to look at are the AC two and AC three positions and let's start with the one that is distinctly harmful and that is head posture bent forward. So we move our head one inch forward from a neutral neck and that means either by looking down or by pushing our face forward with the by looking up that adds 10 extra pounds to the ligaments and joints in your neck for every inch that you move forward. And this is our day in surgery right our head is forward even looking down and open procedures or if we walk by any operating room and look at people operating with scopes will often see something like this, which is an abnormal forward position. What do we do about it to sort of very distinct points one is the table height is critical. Good height should have your elbows at 920 to 120 degrees with relaxed shoulders and we're going to talk about that in a minute too. And here's the problem even if you are the chief of surgery even if you are the chair of the department if you are the shortest person in the room you should be on standing stills i'm operating currently with a six foot four in turn and so i'm consistently on two stools and the operating room. Because the shortest person can adjust that the tallest person has to lean over. Monitor position is critical has to be straight in front of you not twisted to the side and if you want today's trivia to remember it's 17 degrees below eye level is a neutral neck what that translates into fortunately is if you put the top of the monitor at the level of your eyes you are put you're in a neutral neck position. So what about these other ones so back bent forward and twisted so that's not putting the monitors over to the side that's not you know sometimes it's unavoidable like if you're operating up at the diaphragm in an open case you are going to be twisted you're going to be static so we have to deal with that a different way. Shoulders raised is purely a conscious thing so we all of us when we get tense in surgery our shoulders go and the earlier we are in the training the more common that is we have to just consciously say to each other hey relax your shoulders to yourself relax your shoulders. Wait on one leg is one thing that I honestly hadn't thought about until I started studying this and thinking about it but we do tend to stand often in the operating back and forth on one foot and it turns out this is extremely detrimental to your spine so we want to be have our feet even and the way even on both feet actually a little bit on the ball of the foot with soft knees you don't want your knees locked. And how do you do that well so everybody's been in this is actually the oldest bar in the United States. I think it's in Philadelphia so then maybe one older and Boston you may I may need a new picture from somebody but anyone who has been in a bar has seen the brass railing around the bottom of the bar and the reason it's there is the bartenders know that it's you put one foot up you can stand longer and take more beer. So the same is true in operating room if we put one if you put one foot up your pelvis is in a neutral position and so is your spine. But I think probably when it comes to ergonomics one of the most important things we can do our true micro breaks a 22nd pause and this is clear the senior surgeon has to do this has to make this part of it you can make a deal with anesthesia to discuss this ahead of time and we're going to do that. So we're going to look for opportunities during the case because we tend to get the flow and we forget. But if you can remember to do these 22nd pauses to stretch. There's documented improvement in concentration and performance for surgeons who do this but it's also ergonomically extremely helpful. It's also a moment in a case that you're really glued to the diaphragm or glued to the pelvis that you can ask in a stage to do a five degree switch right or left or up or down. Position for the next block of the case and this is the time when you and I and I do this where I say okay let's all do a posture check for a minute and what that is is literally is everybody's neck and neutral position or your shoulders relax and you should wait even when you feed. So if you ask yourself these three questions or if you're in charge ask team these three questions it is ergonomically powerful to help us not be injured. Now one other comment about ergonomics. Another trivia for today there are 11 sizes of surgical gloves. But we all know there's only one size of microscopic equipment and actually open equipment too. And it's not surprising then that we have problems for people in it's also not surprising they were made for very large hands. So people with smaller hands have difficulty and this causes ergonomic problems in the hand and wrist it's particularly true with the stapler. So when possible we need to speak up with our companies and ask them to be working on designs but also just realize if if you are a size seven and a half hand that the person with a six or six and a half is going to struggle with the stapler and it's not because they don't know what they're doing it's an ergonomic issue. Our other place of work unfortunately is also ergonomically very damaging and so just to know to remember that the same rules apply. You need good chairs you need your monitor at the right height or you will continue to be injured here. And it all matters so how often we have our head forward looking at cell phones or anything else is also an ergonomic entry. Now I this is one of the moments when I'm really sad to not be in person because inevitably if I'm talking about ergonomics and I mentioned something about upright posture the entire room sits up and if you did that and wherever you are now. You got it. So the other two buckets or maybe something you haven't thought about quite this way and so and I do think they're the most powerful things to think about in terms of ideology of this epidemic of burnout and the first is failure to recover from injury. I'm going to read this out loud even though I don't usually read long things because I think it's the best phrased version of this I've heard so once entering medical practice additional stressors include shift work long work days high case loads time pressures, poor sleep habits and high performance expectations, challenging patients, personal fears regarding competency and changing roles in the workplace. In addition physician and trainees regularly face suffering fear failures and death as well as difficult interactions with patients families and other medical personnel. What we do isn't routine and all of these things because we're human beings represent small or large injuries that we sustain as part of our work. Some of them are paper cuts but they happen every day to every one of us. They come in many forms they can be the physical injuries of ergonomic along case they can be emotional injuries of being yelled at or having the family that fires you or all the other things that can happen they can be spiritual where you lose your sense of meaning and purpose for what you're doing what you're doing. But they all the injuries are not contained just at work right so if you have a dog that dies at home or strife in your family or get sued that's an injury as well and they can have varying degrees they can be paper cuts that we all know you can die from a thousand paper cuts they can be big injuries though of terrible problems at home or losing a favorite patient or having a major complication. So all of these things happen to us and they are injuries and injuries have to be healed. COVID has added a whole other thing and a whole other level of injuries things that we've had to give up and then it's caused real problems for all of us. We've learned now two years into it to adapt a little bit but the injuries still there. For surgeons we know that you can't get a burn and have it all better the next day why would we think that you can have lose a patient and the operator and go right to your next case without any consequence. There's we need time to recover from the injuries whether they're physical, emotional or spiritual. And then this last bucket of moral distress. This also comes in many forms and in many degrees of injury institutional so policy rules misaligned visions between what we view our role as healers and what institution views our role as moral distress and patient cared insurance denied patients we can't take care of. Essentially not being able to do what's right for our patients because the system is not allowing us to and then the moral distress that we're all experiencing right now is all of the issues in our society are revealed more and we're having to grapple with our history and our own status in our own privilege in an era a place a time that has such poverty racism sexism and all the other isms. So this paradigm you know this is kind of a new syndrome what do we call it. If we love that right when you call something so I think well this i'm going to call this position to stress syndrome I think that's kind of applies to everything and helps us think about this in a different way than just talking about burnout. And that worked finding till I was running this by some friends and in talking them and one of them was oh first thing I did sorry because anytime you come up something new you got to check what the acronym means so pds thank goodness my favorite suits are all of our favorite suits you. Also if you google it and look on wikipedia's photo thermal deflection spectroscopy it's partially the cease syndrome in a cool fictional show it's a little weird particularly dangerous situation weather. I like that one but then I was talking about it with a friend who was a nurse practitioner and she said this is I like this I think this is going to be very helpful but you know I'm not a physician and this totally applies to me but no worries you don't even have to change the acronym you can just call a provider of distress syndrome but the only problem with that is I don't use the word provider. And the first reason is most of the time when you see work about health care providers and where that word came from it came from industry it is part of our industrialized medical machine it implies a prepackaged commodity on a shelf that is provided to a consumer rather than something personalized and dynamic crafted by skilled professionals and tailored to the individual patient words really matter and provider is not a good thing. It's not what what I am or what you are. I also don't use it because in Nazi Germany Jewish doctors had the title of doctor taken away from them and they were called providers. So I decided okay I'm going to call it heal or distress syndrome and yes I did look it up and I couldn't find anything bad that HDS stood for either. So this model I think certainly helps me and I hope hopes you think about ideology you know what are the causes of this thing we're feeling and that's leading to suicide in some of our colleagues and terrible distress and others and it's not lack of yoga and it's not lack of people giving us awards it's something much bigger than that. But if we're going to think about this like physicians and like the researchers we are maybe this helps us but we're a long way from diagnosis right now we have a little bit like Bell's criteria for neck you either kind of have don't have it kind of have it or have it really bad and the muscle up burn out inventory and there are new ones coming online that I think will help really doesn't drill down to where are you on this spectrum of distress. So lots more work to be done in that even more work to be an staging because if you look at staging of distress and burn out and all the vision and you go online you get things like this that I mean how do you measure this how do you have this help you decide what to do and so definitely more work we need to do in staging. I think that we possibly can use the same kind of staging criteria and thinking that we do with Sears and sepsis and when I think about it and I if you asked me what are four stages moving up towards burnout I would say stage one is onset of symptoms of distress usually mild and all of us experiences all of us. It's a very important point to a bad day is not burnout a bad week and struggling is not burnout this is normal response to a very stressful career so it's not again it's about recovering from those and not letting it progress that's important thing stage two most of us pop in and out of this one too significant sense of distress decreased interest and peace people and events increasing anxiety and when we see this this is really. We need to do the red flag you need to take a day off you need to figure out what you're going to do we'll talk about that in a minute to what how to treat the problems that the ideologies stage three for more important right stage three is pervasive distress this is substance abuse or other high risk behaviors this is failing relationships in attention to responsibilities at work stage four now evolves to impairment did a substance abuse or other high risk behavior significant. Breaches in professionalism and patient care and suicide ideation in some and this helps us think a little bit also about those colleagues that we label as difficult colleagues who get reprimanded and coached and fired and maybe we're approaching their issues a little differently than we should as well. So what is the treatment and how do what is this model help us think about it terms of treatment well this is where the model of series and sex this helps as well for us particularly surgeons it's source control remove decreased or modify the source of the problem and provide supportive care. So how do we do that if the problem is insufficient self care you need to figure out what's insufficient is it part of a physical self care emotional or spiritual care and brazil I love this close as you need to hardwire the things that bring you joy so don't make this don't decide you want to be a runner and make yourself go run if you hate running you know if tennis brings you joy then make tennis the top thing you schedule on your list hardwire it so you need to do it. You can't go without it and the things that make you bring your joy in all those in all of these areas hardwire put them on your schedule first. This is the other thing if you're taking notes or a screen grab I want you to get because this model here where this is our work right is you come to work after vacation you do this fabulous case and then the patient has the complication and you recover a little bit but you don't it's still lingering you're still thinking about it all the time and then you have a fight with your spouse. So again it's this inability to recover from these injuries that keeps you in this full tank instead of going below the empty line. What injury are you recovering from it takes time to heal recognize you need that time to heal and that different injuries need different interventions or therapies whether they're physical or emotional or spiritual. For moral distress this is a very cognitive thing you need to reflect thoughtfully on what your own values are and what it is that's causing distress you have to act from integrity to align your values with what you're doing. And then you have to have the moral courage to step out and make those changes. So this model is a beginning not a conclusion I hope is a new paradigm that allows us to come up with new ways to diagnose physician to stress and burn out direct therapy to prevent progression and provide effective treatment and provide a framework for research. But this is not where I want to conclude because as I said at the beginning we don't want to just be okay we want to go beyond that to a sense of joy in our work. For those of you that have not read Dr. Shapiro's article I highly recommend it we're all familiar with Maslow's hierarchy of need. But this is the hot health professional wellness hierarchy and I'm going to spend a minute here because I think some of these details are very important and we're talking about in your group afterwards. So the basic need level one has to be there before you can move up I'm hydrated I have access to food and time to eat I've had enough sleep I have access to bathrooms I have no depression anxiety I'm free of substance abuse I do not have suicidal thoughts I have time and space to breathe. Then if you have those basics you can move up to safety the next level I'm physically safe my patients are safe my job is secure and my future predictable. Then you can move up to the level of respect there's a basic level of mutual respect and inclusion at my work my family time is respected. This is my own my favorite sorry I'm not hassled by it the electronic health record bureaucracy objects and processes work. Cultural violations are addressed. Then to appreciation I'm noticed and appreciated I'm connected by compensation reflects appreciation. And then at the top heal patients and contribute so now we're talking about meaning at work I have time autonomy and resources to do this correctly. I have time to think and contribute. This top level this meaning is something we co create with our patients and our colleagues and is the reason that we do what we do but cannot happen if these other levels of need are not met first. Now one other thought is I think that this correlates with my model as well. That the basics really are about self care and providing physical needs and emotional needs and then when things happen that were allowed to recover from our environment is set up so that to prevent those injuries to start with but finally that this moral distress being an alignment with what we value is a we can have happen at work. And what we value if you look at this pyramid from the top is also at our center. And finding our center and this is where you know people confuse this with religion which I know and you know we all know for many people does not apply or has horribly injured them to where it cannot apply in their lives. But we still have to find that center no matter what you call it or how you acknowledge it so if you do practice or religion you may participate in a community of faith have a prayer practice but for those who don't this is still something you have to nurture and pay attention to with meditation with contemplation or at a minimum with stillness. I think that no matter how you approach this you have to find sometime every day to be still to be physically and mentally still and I also think we need to work every day on cultivating a sense of awe. Einstein says you know one cannot help but be an awe when they contemplate the mysteries of eternity of life of the marvelous structure of reality it is enough if one tries merely to comprehend a little of this mystery every day. So this friends is what I would offer as your practice as you practice medicine which is to look for and comprehend a little of the mysteries around you every day with some silence some stillness and a sense of awe. I'm going to end this by saying that that kind of big context is the other part of finding your center and my favorite quote from roomy which I'll end with is we're all just walking each other home and that's a big context you can take to work every day. Thank you for letting me walk with you this morning I'd be happy to answer questions or have people contact me individually. Well Mary thank you so much I think for those of you who aren't familiar with Dr. Rank you can see why our fellows chose to invite her for her really extraordinary perspective on our careers and our lives and our well-being she's been known to the throughout her career. I will tell you Mary has been personally posturally challenged I haven't sat so properly for 40 minutes in a long time something I'm working on but you're helped and I think there are very few things that you spoke of that didn't resonate with probably almost everybody. I am when you talk about what we strive for what we should strive for actually your last couple slides summarize what I think my job is in addition to optimizing well-being of our children it is achieving the top of that pyramid for each and every member of our department. And as I look at the screen throughout your education of us I looked at various people and names and saw people that I perceived at various times to be in different places and even as a department where we are in the pyramid at different times and your part of the time are just spectacular. Our younger people have really been people to educate us older people you are one of the people in senior emeritus generation who has been on top of this throughout your career but some of us have been dependent over we can take it pain as part of the deal. We've been learning from our young people and we decided to start a wellness program and we asked the young people what is wellness we had some ideas and yes we did the yoga and we did all those things and what they said was you know we could really use some time during business hours to go to the bank to go to Venice to go be a room parent. So we created a wellness Wednesday and Wednesday after the month the fellows are just out of here and several of them have to do the same but it's really really hard and as a department you know you talked about the gratification at the top and I just last week was shown our press game to the sort of surveys that people don't give me started on press gaining. You talk about injury. Exactly. The surveys that people can avoid taking and therefore only a third of people fill them out but our chief experience officer reviewed the results for the department with this their day and she was she was impressed by the dichotomy of the responses of our faculty in that the gratification the meaning of purpose. The questions like you know I find meaning my life I you know I have purpose in my work etc. were all really high but the things that relate to stressors like working well together in teams were more challenged and so you can be as individuals as a group at various parts of your pyramids and it's really our challenge to try to to achieve that and I thank you so much for for giving me this paradigm to think about I'm I'm sure there are tons of a person. A person thoughts and some people may want to ask questions. Yeah maybe. I'm going to stop sharing so that we can all go to the grid so I can see faces and if people don't mind putting on their images. Obviously if there are some who will not be able to and that's fine I would appreciate it because I know many of you and look forward to seeing everyone else's faces too. Any any other thoughts folks that I can. And by the way the one of the reasons I got interested in ergonomic has to do with the scar that's on my neck here so I trained in the same generation I wasn't allowed to complain either I was told the pain was normal and I have a fuse neck as a result of it. We have a number of our faculty with the same star. We have a number of our faculty members. I'm not sure if the club we want to be part of but and but it's a club I want to prevent other people from being part of so. Some of us will remember Dr. Hendren who we lost last week. Yeah my oh my and my condolences every I know that that's an icon of surgery and a great friend is pictured over my shoulder some of us will remember when he had his entire cervical fusion. I and was in the hospital the next day and that Friday night was at the doing a surgical to his president was dancing on the floor with his collar on and so. That's not the best way to cover that kind of entry but that was the generation that he was in yes done up next and that's not the way. May I point out no no no no no no thank you for the example. I came from but no no no no no no no. I'm sorry. I certainly just want to say to the group how much I appreciate your leadership in hearing your lectures but also really being the inspiration for apps starting a wellness committee and. I've been for theme other people on the in our department are fortunate to be on that committee and work towards some of these goals you know I was struck by a couple things you said and just just you know reflecting you know people say well why don't you go do that on your lunch hour or you mentioned why don't you just take the day off if you have. A particularly stressful and you recognize within yourself you have the moral injury or you know take that little time to yourself during the day but then that makes your 12 hour day a 13 hour day so. You know the sheer fact of our commitment our time commitment in this profession almost makes that. In part you know it from the outside impossible so since you've been setting this are there. The little micro burst if you will of things that as a department we can you you've seen people operationalize that are are. Reminders that can help us as a group continue to be aware of this and and and push this forward in our consciousness it's almost like the. You know the unconscious bias training you don't know until you're actually forced with you know learning about it so are there any things that you've seen been successful. As a group of operationalizing this so one of the one of the great comment and it's maybe think of something else so one I just read a very interesting article about how COVID has completely changed the change work right. And I and I would say and with all due respect to Dr. Debaki who trained me and the generations who have been trained by the great icons they had a very distinct pattern of work. That was the way you work that we all were trained in that now has been completely disrupted by COVID right and if you look at at our ability now to rethink we can't rethink going to the operating room. But but other things have shifted and we know this right the time we spend traveling the time we spend in conferences the ability to do things at home with your kid or your pet next to you and often very funny on zooms it's you know we have re thought work in a way that's changed the typical nine to five. Oh hold on. Are you there can you hear me so I got I got a weird message and I want us to take hold of that so that's the first thing is to say I don't think we have to say well we have 12 hour 15 hour and it has to be that way. All right there are days it has to be that way don't get me wrong but the days of getting to the office before the boss and leaving after the boss which was the norm for a long time are gone thank goodness. Let's take advantage of that to rethink I personally believe that if you took any group of surgeons and said okay we have here's our level of how we're working now and what we're covering right now. I know you guys think about the there's 10 of us say that nine of us do all the work and one person's off every 10 days just for themselves as long as we don't drop the level of care or anything do you think we could make that work. I want to give you the 99 times out of 100 if you gave that power to the surgeons and said just make it work make sure the same number of patients you're seeing but so let's all up our personal work 10% when we're here for those nine days so that we have the other day off. We do it and it would be fantastic so think out of the box first of all and I think we're going to go there I think that's what's going to be happening 10 or 20 years from now for sure. The other part is once you know this consciously when you see a partner who is struggling you can go up and say look this isn't you this isn't personal you're not outside the norm this is normal why don't I put in that why don't I drain that access for you so you can go home earlier. You know and take care of each other that way so those are the two comments I would make about that is rethink what what the work hours mean and our appearance at work and how much we have to be at work because some of it's not necessary. And and take recognize we're all walking each other home that work right and so we if we're having a tough day if someone's injured and you recognize it you will do for them as they will do for you and that that should be the culture that we create. Dr. Brin I've always thought I've been sitting here what do you think about teaching people how to say no or to recognizing when we're when our you know our glasses almost full we have this innate desire to always say yes i'm happy to do that i'm happy to help but we already have like 55 different other things we're going to do. So that I think is the hardest thing that I have faced as a junior faculty. And that is the part of your life when you say that and do that and some of that's good because it gets you exposed a lot of things and there's some some you know part of that it's wonderful and then there's a part of it that leads to being exhausted so answer your question. First of all you have to know what you're doing and that sounds weird right but I keep reinventing my own personal organization on how I do things I just I just finished reading a really good book about how to use. Paper or digital as a dump for everything all in how to organize that into projects okay so i'm still reinventing that part for myself because I tend to say yes all the time to so part of it have is to have a very clear understanding and an organizational system of what you're actually doing because we always say oh I can always fit that in I can always fit that in until you see that you actually have about 50 projects. Most of us on any given day and if you take the definition of a project in this book is anything that has multiple tasks that you intend to do within a year. Okay and so that can be repainting your house right so if you have a master list of all of those things when people come to you and you look at that list your answer to them is I certainly don't want to leave you stranded however I don't think I can devote enough time to this to do it well. Can I help you find someone else and if you really get stranded let me know there's nobody who's going to say he didn't want to do it that's actually a sign I think more of professional maturity that you you actually know what you're doing and you know what your time constraints are. But I will say to it's also a leadership issue right you've you've the leaders have to know the same thing they have to know where the projects are distributed so that they're not overly going to the person who always gets it done and always says yes. I hope I didn't stir up the suit too badly there no I'm actually I'm thrilled to see to see you say that and see Ben smiling because Ben I had a discussion just. A few days ago about something he'd love to do but he has a really really full play right now in the North North response bill and he said yeah I don't think I should do that right now and so it is it is a younger people who sometimes are teaching us the right way to do this yeah well we need we need to reward that when people say it because that is that is a sign of professional maturity. Jamie. Dr. Brant thank you so much for doing us again I just have one question from the trainee perspective we have some residents and obviously the fellows here this morning when you don't yet have that opportunity fortunately I will have a little bit more of this opportunity soon but when you don't have that opportunity to be in control of your time and often in control of your priorities. We all have home and life outside of work but it work where as a trainee that's expected to be our number one priority so when you don't have control over that how do you what advice do you have for trainees on maintaining this sort of balance. I think that it's a very good question and it's not just trainees because all of us have periods of time when you know a partner gets sick and you have to up your time and you know so it waxes and wanes but you're right you guys are in a much higher constant baseline. You the part there I think to realize is that it's all about recovering from all of this stress and so the things that appear to be the easiest way to recover which is to sit around and watch TV and drink beer and eat bad foods because it makes you feel good right at the moment is actually going to backfire and taking you know having a little tiny bit of organization about paying attention and it doesn't have to do not try to check all the boxes right. But to say i'm important enough that i'm actually going to make sure that I take that extra 10 minutes tonight to pack all my food for tomorrow and then when you see that food tomorrow it's not just the food and the fact that it's going to make you it's going to feel you better and you're going to feel better but you've taken care of yourself and that message actually helps a lot. And then when it's really bad you just have to surf that wave because you know it's going to stop and you know you're going to have time to do something else and and part of it is when we're in the midst of really a very tumultuous time at work we tend to think and and think that we're not going to come out of it very easily so you just got to remember you're going to and then whatever little thing you can do to make it better a little exercise a little eating well. Sleeping well sleeping a little more and you know all of those things do it because that will help. Another minute or two. Anybody well Mara I want to say that I think that this is a discussion that every department of the country should hear this is particularly timely for us all groups go through this process that you discussed in all the different categories we have happened to have quite a string beyond COVID in the last years or internally of people being physically. Unfortunately and everybody thankfully recovering but with others hiring to and and gladly stepping up to to step in for for those who need to be away we have so we know actually and and it's it's good to remind us at that higher level of the pyramid how that helps us as well. I think it's quite a lesson to see how somebody with the senior status to experience a doctor Brad can actually be leading usually we think of the younger generation having to think about these topics but but she's been an international leader this throughout her career I will tell you one story but when few years ago so for younger people convinced us that we needed to have a social media presence for the department. It came to me a little sheepishly figure I'm not from that generation which is true and said well you know all the major departments of surgery now really have have Twitter accounts that's how they sort of have a presence and communicate to trainees and others about what's important happening to the department and it's usually that happens you know under the handle of the chair of the department which I just isn't true anymore which changed that it came to me this said. I can't really surprise that you have a twitter handle. I said I do I said I actually but you've never used that I said no and I said so I'll tell these people now the reason I have Twitter handle is must have been 15 years ago Mary and I sit next to each other at the AP. She sort of a section at the breakfast session and she was on her phone you know typing everything that we're that we're learning in the session and like what are you doing? She said I'm tweeting out all the learnings and she says Steve you don't tweet and said no I just don't really know that's for the kids and she took my phone and she literally made me my Twitter account which I it nearly never used until some more younger people took control of it and have my password and I've learned never to do it myself. They switched out to a separate departmental handle but so Mary has always been ahead of the rest of us in staying current and so for that and for everything you've taught us this morning and all the incredible strength and character you've given to trainees that's right and we thank you. You're saying exactly. And we will have you back with it lobster and beer anytime. Alright thank you again at credible honor and wonderful senior faces and I look forward to that. Ring check. Thank you so much.