Dr. Jo Shapiro - Peer Support: Mitigating the emotional stressors faced by healthcare providers

but to combine Grand Rounds, this is part of the Help in Wellness Lecture Series. And I am beyond delighted to be introducing a friend, a colleague, Dr. Joe Shapiro. She is an associate professor of Oto Lerengology head and ex-surgery at Harvard. Is principal faculty for the Center for Medical Simulation in Boston and is consultant for MGH's department at the anesthesia painting critical care. The reason she's coming to us today is her expertise in peer support. In fact, she founded Brigham Women's Professionalism Peer Support Program in 2008. She directed it for 10 years. It really truly is a model for large institutions seeking ways to enhance the culture, the psychological safety, overall improved clinician well-being. She has, I know, consulted to a new rural group forming peer support programs. She has a ton of athletes. And frankly, I told her early that it's morning. I think the kids refer to this term as stand-girling. I very much look up to Dr. Shapiro. I can't wait to hear what she has to share with us today. And I'm sure you will feel the same after hearing her. So without further ado, I will turn it over to you, Dr. Shapiro. Thank you for taking the time to speak with us this morning. It's such a pleasure to be here. And to see you, Dr. Vincent, and all of the so many people that I used to work with when I was doing Odelearnology and including Pediatric. I wanted to say that before I just start the presentation, that how deeply I appreciate that work that you do as anesthesiologist, obviously, as a surgeon, we can't really do nothing without you. And I just love the teamwork and the expertise you bring. It's just such a beautiful thing. So thank you really bottom of my heart. These are my disclosures. I've been trying to also be aware of my own privilege and bias so it doesn't as much get in the way if I were to wear a bit. So this is a quote from Parker Palmer institutions where the human heart either gets welcomed or thwarted or broken. Personally, my training and surgery did not really lead me to acknowledge this or think about it. We were taught that everything that happens to our patients is on our shoulders alone, which is great in certain ways. You know, a lot of personal responsibility, love that. But the downside of that was we were also taught literally don't trust anybody or you can't trust anybody. And that of course was contrary to the lived experience of all of us really. I mean, we're so interdependent as colleagues and teams and specialists and even beyond that, part of being part of an organization actually has a huge effect on us and the outcomes of the work we do. And so the more I matured in my career, the more I saw this to be true and have been very interested in what organizations, what they do to us for us with us. And I thought Parker Palmer really says it well. So on the positive side, I'm going to talk about medicine as a profession, as a culture in general, being very respectful of differences. I've had the privilege of working in multiple different countries around this and lots of different size and shapes that helped organizations in this country and that we have our differences for sure. But medicine as a profession is a remarkable consistency every place I've been. And so one of the things, there's so many positive things, but I'll just pull one out for it's very meaningful to all of us, which is that we're all healers. And no one's going to take that away from us. And so I think that's a beautiful thing. I do think if you're going to really work on organizational change and creating the kinds of organizations that welcome the human heart, you really have to look at the dark side. So this is for me one of the dark sides, which is that for many years, our system has treated us as an inexhaustible resource, ignoring our physical, mental and emotional health. And we've internalized this. This has really become part of the way we think of ourselves as we are inexhaustible. So we've got acute events like medical errors, patients and complaints, litigation, chronic stressors like COVID, racism, harassment, disrupt the behaviors, work loads, lack of autonomy. And these have all put an extraordinary burden on physicians and other healthcare providers. So we know that, right? Those are there. And this is rhetorical question, but how are we actually going to sustain our joy and work, which is what IHI really calls LB, well-being, if we don't address these challenges to our well-being. And so I'm going to talk specifically about one way in to this, but I want to put it in perspective. This is a Venn diagram I made because I was really trying to get my arms around, what are the different initiatives? Well-being is such a huge topic, right? I mean, it's huge. And so what are we talking about here? And so this is my concept of the way to think of well-being efforts. It's a little different from some of the things that are out there. So bear with me for a second. For one, we've got individual resilience, right? And to exaggerate in a bit, we're told which is supposed to be training for a marathon and cooking your own healthy meals and meditating twice a day and maybe doing some yoga and also have some volunteer work. And yeah, I mean, I'm not making fun of any of these things. I think resilience efforts are really important. But at some point, it's unfair to ask us each individually to breathe through what can be really a toxic or dysfunctional system. So we can't just put all the load on us, right? That's just not fair. So we need to think of what are the other factors and the other, which is huge, I think, as relational work. What are, where are we in a sense of community? And certainly I'm a senior physician. And when I trained an early on in my career, really up until the past, I don't know, decade or so, we had more of a sense of community because of the way medicine was practiced. It was just less isolating than it is now. The pressures and the way medicine is. And that's not going to change. But because we are social animals, we need that sense of connection and that feeling of support and being part of something that's more than ourselves. And so I think we need to find ways of doing work that draws on that. And then there's the organization, which I think, in the beginning, nobody was really holding accountable for what does the, and we are part of the organization, it's not like them and us. I mean, we are the organization. I think we think, especially in terms of the leaders of organizations who do, to a large extent, control the resources. What are the systems that are set up that are doing things that are undermining our well-being? And really, we need that those need to be addressed. And also, are they, what are they resourcing? And so, I think, let me step back and say, I made the event diagram. So I put peer support right in the center of the intersection. Clearly, it's about helping individual peers move through traumatic or just extremely stressful circumstances. So it's definitely some resilience there. It's quite relational. It's done by a colleague. And that colleague in a way is standing in for all colleagues because we are, you know, we're connecting the person back with our community. And then it is a huge organizational component, both in my belief that these programs need to be resourced. And also, things will come up that are organizationally dependent. That really, you know, for individuals and groups that are really undermining well-being and that the organization, I believe, needs to address. So that's the perspective of what I'm going to talk about is I'm not coming here to say, you know, oh, this is the best program. It's the only one, you know. Now, I mean, of course not, there is no best. But on the other hand, we have to do something. And I think I've always believed just, you know, as a clinician that these stressors that we experience are so extraordinary and so difficult in the setting of how we've, you know, come to think of ourselves, which is that we're not supposed to feel anything. That we just need to really address these. It doesn't mean we don't need to fix the, you know, EHR. It doesn't or change our schedules. Those things should happen too, right? But I think this one is a big one. So I'm going to talk about the effect, emotional effect of errors on clinicians. Why? Not because it's the most frequent thing that happens to us and goodness, it's very rare in our career, but it will happen to all of us. So we have that. It's inevitable in some ways. And we have, there is so much data about the effects that it has on us. And also because when I do training to be, you're so into trained peer supporters, I focus on training to peer support for an error because it's the hardest to do for all the factors that you know and don't mention. And so the principles are the same, no matter what you're pure supporting for, whether it's chronic stressors or acute one like this. And so it's a good, it's a good one to anchor ourselves in. So let me, let me bring this down here for a little bit. And then I promise I won't leave us in the nature. With experience sadness, we realize the patient's been harmed. I think close on the heels of that comes a sense of shame. And none of these is universal, but they're just very common. And shame is where you go from saying, I feel really terrible that this happened to, this happened because I feel terrible, but it happened because I'm not good enough. I'm just not good enough at what I do. Maybe I shouldn't keep doing this. They can really kick up the imposter syndrome. It's very devastating emotion shame. And you know, I was always curious about that. And there was a really good study by Helm Rike, who looked at the similarity between aviation and medicine and found that both stress and need for perfection and a deep perception of personal invulnerability. So translating this is, we still think, we're supposed to, the way to keep patients free from harm is to expect perfect performance from each of us every day, which was a lovely idea, but completely impossible. You cannot eliminate human error from any enterprise. It we are wired to make errors. It doesn't mean we don't have a responsibility to decrease the chance that we'll make an error personally and that the system should be careful not to set us up to make it more likely that we'll make an error. And we have to make sure that we don't let the errors that will occur from reaching the patient, but that's very different from saying, we are never supposed to make an error. That's just impossible. And yet I don't think we believe that yet. Then there's a fear and we're afraid of a bunch of things. I think if you reflect for a second, if you remember either having made an error or being proximal to one, I'm in medicine that we are afraid of what will happen with the patient and the family, will they lose trust in us? What will our colleagues think? That's a huge factor for us. Will we be punished in some way, some ill effect on our career or even worse, some kind of action against us and or a lawsuit? And I think this brings on some anger about why the system is setting us up to be afraid. Did children send out a memo that you're done with shame and blame? Yeah, right. Nobody got that memo anywhere because you don't take a memo, you don't send a memo to erase decades and decades of shame and blame. That, the shame and blame is how we used to approach when things go wrong. And we thought it was the right thing because if we make that person feel bad enough, they'll never make that error again, which by the way is questionable because it really doesn't help learning to shame and blame. But in an event, it doesn't help prevent errors from other people happening in the future. And so it's a terrible, terrible approach to patient safety. It undermines patient safety people or afraid of reporting, et cetera. And so we need to be done with it. And we are supposed to be done with it. We've all moved to a just culture or a safety culture where there's both personal accountability and systems accountability. But I don't know about you, but I've just noticed that we don't always live in the just culture in medicine that many of the things that happen can be done still in the old, old way of shame and blame. This is a really interesting study. And it looked at very specifically, it looked at what happened to referrals to female surgeons after a patient death versus referrals to male surgeons after a patient death. And for women surgeons, their referrals dropped by 54% where there was just a small stagnation of referrals for male surgeons. Well, so this is, yes, unconscious bias. But the reason I put this here is because to me, it's an existing example of a proof that we do judge and punish each other, implicitly here, unconsciously. But we are judgey of it. And this happens to be specifically gender-based, but that's not universally the case in other circumstances that we tend our first reaction to be, I can't believe she did that, I can't believe he. Why did he ever do that? And that's just a natural human thing to do, but to stop doing that, to stop doing that shame of blame, we need to just be aware of it and then manage it. We're safe. You know what? He's really smart. I'm sure he had reason for that. Let's find out. And then if you look at many, many internal and external regulatory processes, and every country I've been to has some of these, one or the other, where we're responding in the organization or from without two events. And they can be done in a very just culture fashion, but certainly not always. And beyond M&M and root cause analysis, there's department of public health, Board of Registration Medicine, in the Netherlands, it's the inspector in the UK, it's the Royal College. We've got the Court of Law and the Media, which of course, these are especially the last two are shame and blame writ large. I mean, they're not done in a learning and growth mindset. It's who can we punish and get money from? So all of this can make us angry, because it's not the way we know it should be. And then lead to these emotions can lead to a sense of isolation. And again, we're very social animals, humans are, and isolation causes acute and chronic stress. So I just want to briefly talk about COVID because it's a very good example of a chronic stressor that has a different set of emotions, all of which are pretty intense. And I have that privilege of being able to provide, peer support, obviously, many years before COVID, but certainly since COVID began to colleagues. And this is what the emotions that I've noticed, my experiencing and others experiencing. And one is grief, this is a loss that we've all had, experience many, many losses. And then guilt is such a big one. And I just want to say this, we are so wired, I think, in our profession to feel guilty, that we're not doing enough. We're not meeting expectations that have been set for us and that we set for ourselves. So I think even being called a healthcare hero, which comes from a good place, makes us, sets us up to when we are too tired to keep working, when we are too overwhelmed with the kind of work that we're being asked to do and the intensity of it. When we see things that are incredibly upsetting, that somehow heroes don't flinch. And we're human and we kind of should flinch. And so I think these unreasonable expectations cause guilt really unnecessarily. And then there's fear and anxiety, which I think everybody really experienced, especially in the beginning, still some lingering. And then some anger about the way we as a country, in particular, have handled this and the disproportionate effect, unvolvable populations. And then of course, we all have had things to be grateful for. I was telling Dr. Vincent, I got COVID in March of 2020. I was pretty sick just short of being hospitalized, but I was cared for at home by my, the pulmonologist husband. And I made it through. I was pretty miserable. And I wake up every, really, every day grateful that I didn't die. And grateful that I didn't get any significant long-term complications. And we've all had so many things to be grateful for. And what I've noticed in providing peer support is that physicians in particular feel guilty about being grateful. And at being in contrast to some other emotions they're feeling, and you know, my thought about that is they don't cancel each other out. You can hold grief in gratitude, for example. So everything I've talked about, these are normal reactions. I mean, we wouldn't want to train a generation of clinicians that was like, you know, things happen, so my fault. No, I mean, we should, we really should feel bad, right? That's a normal caring, compassionate reaction to what first responders call abnormal events. It's the things that we see in our profession that are just, you know, out of the ordinary for most professions. These are, that's what's abnormal. So we're not trying to tell people, you know, that they shouldn't feel things. And many times we move through this, you know, time can heal. But you know, sometimes it doesn't. And recovery is thwarted, and this can cause significant harm to ourselves each other and our patients. So lots of studies to show this is just one, I'll throw up there that, you know, after this was a physician study, I mean, the effects aren't limited to physicians, but some of the studies that, you know, I focused on physicians, others not. Lots of people suffering after, emotionally after errors. And you can see here interestingly, if you look at the serious errors in red, compared to the near misses, that even with a near miss, where the, you made an error, it didn't make reach the patient, but it was still felt really, really bad and had lots of fallout, as you can see, in many domains. And I was involved in study where we compared emotional fallout from errors of nurses and physicians, the Brigham-Rumos there and a hospital in the UK. Interestingly, no differences from any of those four groups, but many people experience some significant negative impact on domains such as work performance, personal life, or colleague relationships. The studies have shown that burnout and depression are independent predictors of having made a recent major medical error. And we know that if you've made an error, you have higher chance of becoming burnt out. And if you're burnt out, you have higher chance of making a medical error, you know, regardless of the cause of your burnout, which we know is multifactorial. So we've got to pay attention to this. We also know really alarmingly that making a medical error is a risk factor for suicidal ideation for physicians. It's a risk factor for suicide. It's not the only factor, but it is a risk factor. So we've got to do something different here. We have to intervene at these times. So we did a study, we've tried to look at, how can we facilitate coping and resilience on emotional stressors on physicians? This was a physician study. And we asked lots of different questions about different stressors. The graph I'm going to show you next is in response to the question, if you were involved in medical error, where would you want to get support from? And 88% wanted to get support from physician colleagues. 48% from mental health professionals and the AP less. We have great all of our hospitals and healthcare systems, really, most of them have really good behavioral health. But that's not what we want to talk to at these times. You know, we want to talk to peers. Another study looked at that, which facilitates resilience, which can be defined as growth after trauma. What are the things that actually facilitate resilience after a medical, making a medical error? One of the factors was talking about it with colleagues. You got to look at the data and use the data to actually construct programs. So we decided, okay, we're going to start a peer support program, a formal peer support program. And I just want to show you where this fits in to a spectrum of support, because it is not the only way to support each other. We have, I bet everybody in this presentation has done, which is informal peer support. You're checking on your peer, hey, how's it going? I heard you had a tough week last week. And that's a good thing. Sometimes not so good, because we do tend, if you're untrained, we tend to minimize, try to minimize our colleagues pain. Like, hey, that's not so bad. You shouldn't feel bad about that. That's not your fault, which comes from a good place, but minimizing someone's emotions actually is not helpful. But anyway, it's also sometimes not enough. I mean, if you ask me, hey, you know something happened for the OR, last week, and you say, how's it going? You're not expecting me to, you know, have you sit down with me for 45 minutes to an hour and let me unpack the emotions I'm feeling, the devastation I might feel. That's just not what we're prepared to do, or trained to do. And so formal peer support is a step further, which not everybody will want your need, but many people will. And so it requires, I believe, training, because it's non-behavioral health clinicians, like us, who are providing the support. And we have to call on stuff that we're not used to doing in patient interactions. For example, I think all of us want to fix problems. That's why we went into medicine. And you can't fix your colleagues pain. So it requires some training of a way to approach your colleague in a way that helps them move through the stressor themselves with some kind of guidance. So it's not just empathic listening, it's that, but it's more. And so I think we need training for that. And I'm biased because I do the training. So I want to put that out there. That's why I started doing training because I believe it would make us better peer supporters than we would be otherwise. Now that also will be enough for many people, but not all. And some will need and want further professional resources. And yet there's such a barrier to our being willing to get them. And so I'll briefly mention those barriers in just a minute, but part of being a peer supporter and part of the training is to destigmatize and facilitate if wanted further professional resources, if people want more of a longitudinal kind of help. Because formal peer support is really still kind of it's a one off. It's meant to, it's emotional or psychological first aid is what it is. And so it's fantastic. And it isn't always enough for everybody. We need to know that. So these are the principles of being a peer supporter is giving your loving presence to your colleague, which is not a throwaway. We don't focus that much in that way as a routine. Providing psychological safety for someone to talk about how they're feeling and path of listening and validation of people's emotions. And then more than just saying, while that sounds terrible, really hard, which is really important to do, but it's not all you can do is to use non judgmental curiosity, reflective prompts, problem solving guidance. So you're not fixing it, but you're helping them figure out ways forward to move through this, exploring their own coping mechanisms, helping them reframe and then if an offering resource connection and appreciation. So how do you operationalize a program like this? Well, learning from, I'll say trial and error, since there were really weren't any formal peer support programs like the one we wanted to construct back in 2008. We did some things right and something's wrong. And so this comes from my experience in helping and then helping dozens and dozens of programs start peer support, organizations start peer support programs. This is a quote from a colleague of mine. We wrote a opinion piece in New England, journal about support. If you believe, we didn't put this in the article, but if you build it, they won't come. And it comes from our observations that every, every healthcare organization say, oh, we have support for our physicians and other healthcare providers. Yeah, there is support, but it's not utilized, rarely utilized and it's not utilized because of the barriers and cultural and structural that we have to getting that kind of help. And this actually is one of the findings from the study that we did that I showed you, which is when we asked what would be barriers to seeking support would be lack of time, stigma, confidentiality, and also how do I get in, I don't even know how to do this. No surprises, there are no surprises there whatsoever. I also put together these, what I think are cultural barriers that we have in medicine that we're strong and strong needs denying our own needs. In fact, we know that really vulnerability is straight which shows tremendous strength to be willing to access your vulnerability and to be able to move through it. The able culture of science, which leads us to feeling very alone where the only one suffering is what it feels like. And then this, what I alluded to before, which is that yes, yeah, I feel these things, but my family, my colleagues, my, you know, our communities, whatever, they're more important than I am. And this idea that self-care and self-compassion are selfish. And we were raised in medicine to think that, which is, look, hey, I'm not talking about like, you know, every day sitting and exploring every emotion and then going to the spa for an hour or two, sounds great, but come on, you know, we've got work to do, we're busy. But never caring for ourselves, never processing our emotions, that's what's not sustainable, really. That just isn't sustainable. We know that intellectually anyway. So all of this, this is leads to my recommendations and my experience that peer support ideally should have a reach in component. Of course, people, they do get to you and, you know, say, I need help. You should be able to, you know, make it easy for them to do that, but you need to reach out as well. Because it's unfair to put the burden on individual clinicians to say, this happened and unsuffering because of it. For all those barriers I talked about. And then also, why would we wait until people become stressed instead of knowing that there were these stressful chronic or acute stressors that people were experiencing and offer support? If they don't need it, that's fine. It's not a problem. But why not offer it? Not wait till, oh, let's just see how he does after this, right? Now, you know, that's just gonna miss a lot of people and then people are gonna suffer. It can be a bit late, actually. And then integrating the whole concept of, of, you know, being entitled to, being supported into our clinical processes and into our culture. You know, what about, you know, the end of the week with the team saying, that was tough that week or, you know, the end of the day, you know, hey, I just wanna acknowledge what we saw and experience is really difficult and just acknowledge that. And then, you know, mention that there's support available. I think anyone who's been named in a claim should have an outreach for support by someone who's been there. And that's what we did at the Brigham, every single person who was named in a claim got a letter from me, an email from me and the chief medical officer saying, hey, you know, welcome to the club. But, you know, we understand a lot of people are going through this and, you know, blah, blah, blah. And here's some things, reactions that can happen and this is a resource, by the way. I'm on the advisory board for here. It's not a financial thing, so I don't disclose it. But I think everybody should know about this, you know, and that there's a stress resource website. But anyway, more than that, they should have a reach out of what, hey, I've been there. Can I, you know, would be helpful to talk to me, I'd be happy to talk to you about it. I think it should be routine. I don't think there's any question. I'm gonna leave this in case. I'm not gonna be so serious about it. But it's not just errors, as I said, you know, adverse events, even without an error, helping communicate with patients and families after adverse events, which is disclosure coaching, really important, help with chronic stressors, like COVID. Emotionally stressful patient deaths, or things that we see that are not the result of our care, but still feel awful to witness. I mean, as, you know, when you're specialty, you know, you know, you know, you're just seeing really sad things. End of life care, patient complaints about us, patient aggression. Unfortunately, that's really present. That happens. Lots of different things, I think, we should be there reaching out to offer support. And then offering further resources, is just some of them that I think, you know, every organization should help people connect with if they, if they choose to. And I think that, you know, the leaders absolutely need to listen to, you know, what else. And respond to thematic concerns that we will hear about when we do peer support. And this is, this will happen. That things will come up that are thematic, that keep happening in the workplace that need to be changed. And I think we need a every, every healthcare system needs a way for those concerns to be heard and listen to and respond to, and it doesn't wait for like crises to, to let people talk about what they see as, as problematic. So I think, I believe that, you know, peer support is a culture change driver, you know, beyond actually even the beauty of helping the colleague through something. That it says in so many ways to, you know, to, to our people that were really actively trying to move away from shame and blame and promoting just culture. That we are not invulnerable, that we are human, we will make errors and that's human factors data. That's just the way it goes. It's awful, but it, it didn't happen because we're bad people and inadequate professionals. The expectation that we're supposed to move through all these stressors and just, you know, be tough and put your head down and get your work done all the time, you know, never, never, never taking any kind of pause for ourselves to regroup and says, you know, what these reactions are normal. They come from carrying and compassion, not from weakness. And then of course, going away from isolation and moving towards this idea that you're part of a community. And I think the big relief that I hear from, and we actually have studied this, together our data, and it is borne out by the data, is that it really helps people feel less ashamed and less isolated and moves us also away from, you know, on thinking that self-care selfish and gets us back to doing what we do well, and showing up with compassion for our patients each other and ourselves. And I want to say that one thing that has, well, I'm going to just talk to you personal story. So I was saying that I got COVID and, you know, I was really getting, you know, sort of getting better. And it was, it was literally the first week of March. And people just, I mean, there wasn't that much out there as to exactly what the course of the illness was. But we were seeing people who were doing fine and then, you know, then we're crashing. I mean, they were doing not fine, but they were, you know, kind of holding their own and then boom. Or they were, you know, seem to be sort of stable, but then, you know, progressively got worse. And so I was getting worse and worse and worse. And completely continuing to do work from home. I was doing, you know, I did, I did grand rounds. I did. I provided peer support for people. I just was like business as usual. And I was in no position to do that. I was really starting to get sick and feel horrible. But I, I, I, I was really my knucklehead phase. I kept thinking like, well, people need me. Well, yeah, but you know, Joe, you're not the only one. And also you're sick. So my family and friends and colleagues were, you know, finally just said, you just, no, you're crazy. This is not sustainable. You can't do this. You have to just heal. And it became evident that that was what would, what I needed to do. But I was thinking, oh, my gosh, I'm supposed to be the expert on this. And I am doing the same thing that I'm helping peers stop doing. And I need to apply this to myself. But it really, really drove home for me. The incredible amount of inculturation that we have that says, I'm not supposed to, you know, I have to be altruistic at all times. And, you know, yeah, that's great. But it's not sustainable. And so I just want to say that, you know, I think this is such an important, it's important, even beyond errors. It's important beyond, you know, it's really important for us to look at ourselves and say, when do we need to keep working? When do we need to take a break or when do we need to reflect or really change the system? Because this is not sustainable over the long haul, not over the long haul. And that, I think, is this is why, you know, this is going to take time. Not, you can start the peer support program. You are, people can start it like, you know, in a week. I mean, maybe that's a bit of an exaggeration, but certainly within a month, it's, you know, I, I, like, we can all, you know, help set that up. That's not the question. It's really, let's get started doing something, right? And we're, and, and then moving this through our culture as this is what we do, because we care about each other. And the organization cares about us. And this is what the organization does when he shows the cares about us. So, I want you to notice that I haven't used the term second victim. The patient advocates I work with don't like are referring to ourselves as victims after we've harmed them. And so I stopped using it, even though I think it was a great term. And also to me, it has a lack of agency. This is a quote not related to medicine. The parker Palmer said, which is that we're not victims of the world. We are its co-creators, which he sees as a source of awesome responsibility and profound hope for change, which I, I really share that as well. I think we can do a lot for ourselves. Yes, for each other. And, you know, as part of an organization for, for really all of us on, on a, on a big, big scale. I wanted to say that I wanted to stop. I was going to read a poem, but let's say not to, because I really want to hear what your thoughts and reactions are in questions. Of course, welcome. But also, where does this land with you? And I know, you know, you've got some wonderful leaders who are doing this and would love to hear from them. But, you know, where do you, where, where does land? You know, what are you thinking? And then, of course, I welcome any questions and really, really want to thank you for. Like I said, all the work that you do clinically, but also showing up and being here and being willing to learn and grow together. Dr. Vincent, would you like to invite? I know what your culture is around this, but, you know, just for my point of view, if you feel free to just, you know, tell me what you're thinking. Thank you so much for. Incredible lecture. The question I had is, is with barriers to seeking peer support? I know there's a lot of states moving toward, or not a lot, there's a couple states who've actually introduced legislation to make peer support a non-discoverable relationship. And I know the National Academy of Medicine's action collaborative is in support of making that non-discoverable. Do you think that will have a perceptual impact on people's willingness to access peer support? Or do you think that's? No, but I think it's still a good thing. It should be there anyway. So, but my, this is my experience is that discoverability is not a barrier to, to, to support. I don't think we're, but well, let me say this, the biggest barrier is, is this idea that we're not supposed to, you know, be suffering. And so, in Massachusetts, as you know, unlike some other states, by the way, peer support conversations are protected, they should be, of course, they just don't happen to be a Massachusetts. So, we went through, you know, a lot of thought about, like, what should we do it anyway? Because it's discoverable, could it harm people? And here's what we concluded after really speaking to the defense attorneys are, you know, the, a crycoe and our risk managers, et cetera. And it, that, and this is, and this is my position. And it's, it's how I felt lots of other organizations do this, even though it's in their state, it might be discoverable. And so, the risk of not doing it, we have the data, we have the data. And so, we don't, it's, it's a risk benefit, you know, just like surgery. And, and really one so outweighs the other. And how are we going to mitigate the chance of this, you know, being used against somebody who eventually becomes a defendant? And the answer is, it's so unlikely, and it's never happened to my knowledge. It's unlikely to be used against them because it's not what the plaintiffs attorney are asking for. They want it when they say, have you spoken to anybody about this? They are looking for you to name a colleague who you talk to who said, I think you, you know, I don't think that was a right approach. And they then will use that against you. But that's not what happens in peer support. Yeah, people talk about that we definitely let them talk about an encourage them to talk about what happened. But as a peer supporter, you know, I mean, you're not going like, well, why didn't you call, you know, cardiology consult or it's not, you're not doing an event analysis. So if they subcended me for having peer supported you, for example, what, and plus no notes, no, no peer support conversation as any, any record of it. I mean, you know, in terms of written down or anything, what would I say, you know, there's nothing we could get for me. And in fact, the defense attorneys were like, hey, bring it. I mean, we would just show that the, you know, that that defended really cared about this and wanted to, you know, make things better and, and to, you know, and felt really bad. And that they were, you know, all quite in support of doing this. So I honestly, it's the same way I don't think apology laws really changed people's ability to make apologies. The barriers come more internally and, you know, and fears around, you know, just what people will think and those sorts of things. So I don't think a lot like these laws would make a big difference. I think they should be in place 100%. But I, no matter what. So I think you need to reach out anyway. And when we reach out, I've not seen anybody say, no, I'm not going to talk to you about this because I'm afraid of discoverability. Never. I've never, ever heard or, you know, people that doesn't seem to get in people's way at all. So I still think you need to do the reach out. Yeah, I agree. I mean, I think I think no plaintiffs attorney is going to want to put someone on the stand to humanize the defendant. Yeah, and, you know, it's, there's a couple questions in the chat. I just wanted to bring up someone asked, thank you for the presentation. Do you have suggestions for strengthening or improving our sense of community in the setting of COVID and social distancing? Some, but you haven't heard of. I mean, I'll tell you what I think I've seen helpful in different organizations, you know, obviously using this remote. But actually having, you know, organizing, if you will, I want to say, I hate to even use a word meeting, but organizing an event where we are really talking to each other. So for example, this is, you know, very specific, but, you know, I was asked to work with a group of women physicians in Michigan, you know, if for like a little mini retreat on leadership in medicine, women's leadership in medicine. And, you know, it was it for them. It was a lot. I didn't know any of them, but they knew each other, but they hadn't been so, you know, they're just had been connecting and they really used it. And we said that this up is a way for them to, you know, we do breakout groups with small, you know, small groups and then come back. And, you know, I did some facilitation and a little mini presentation. But yeah, just having waste. I think we have to use zoom for now. I mean, soon, hopefully not, but you know, bring people together with the idea of setting up psychological safety and social networking stuff, the less to say, you know, talk about how we're doing. And, you know, yeah, so that's one suggestion. I think we're just going to have to wait to do some of the, you know, going out to dinner type stuff. But that'll happen. Somebody asked, Brenna was it about, let's see, it's not just asking about your works, like you understanding that most of us have to go home and jungle, what happened at work with being absolutely. And so I got to tell you in peer support. And I've done a lot of peer support. And I do when I do training, I do a simulation. Right. And so I'm doing peer support for somebody who's just, you know, doing, I mean, they're just showing up. I don't know them. But really 100% of the time, I'm going to say that the discussion does, there's some discussion about this effect, you know, how it affects them as a parent, as a, you know, as a spouse, et cetera. Because that's what the experience is. And that's, you know, the training and being a peer supporter is to give people even to prompt them to say, you know, do you have support, you know, are you accessing supported home, those sorts of things that it gets people, but people even spontaneously will talk about it. Right. Because this is these stressors, even though they happen at work, they affect us 24 seven. You know, so that is absolutely a part of peer support is inviting that, you know, has this affecting it when you go home. Well said. And somebody had a resident had a question, I think. Okay. The resident peer supporter. Yeah. Yeah. So this is a common problem. And I, you know, with organizations is, if you do peer support, this has been my experience. If you do peer support is solely a reach in for all those reasons that I said, you're not going to, you know, identify a lot of people who need it and want it. And the big advantage to doing reach out is that it normalizes the fact that this, these can, these events are, or these circumstances can be really stressful. So the, even if, and then I'll answer the question as to how to do that, but systematize it. But I just want to say that if I reach out to, to you, and, you know, say, hey, I'm reaching out because everybody I know has gone through, you know, I and everyone I know has gone through things like, and some of us find it helpful to talk to a colleague, you know, is that something you'd like to do? I'm just, even if you say, you know what, I'm good. Okay. But I've already done an intervention. I've already said, I'm here. And then I'm going to send you some information about, you know, about other resources and reactions and those sorts of things. Is that okay? Sure. That's great. That's an intervention. It says, I'm there for you. And some people, that feels just good enough so they don't feel isolated. But yeah, you have to have a system where the triggers are made known to whoever's running the pure support program. Right. And so you want to get it out there that when an event happens, no judgment about how the people are doing who are involved in the event, but just that gets reported. So it could be, for example, fits about errors, it would, you know, risk management automatically tells the head. So this is what we had in the bergam risk management. You know, they knew what was happening around the hospital. They would tell me every time. I mean, obviously if it was a dose of gent that was missed or something, you know, not really super minor, but you know, anything, you know, anything at all that was of import. They would say, you know, Joe, this is, you know, what happened here, the people involved and then I would assign a peer supporter, you know, for to each of the people involved. And, and I had to train them, but I mean, I had to have the risk managers, you know, lower their threshold. I was like, don't wait till you think the person who calls you or reports this needs help. But you don't know they could sound fine on the phone, but you don't know how they're doing it. Plus we want to normalize the outreach and they gradually started to say like, yeah, we're just, we will tell Joe. And that's the, so that's an example. We had a thing where anybody named in a claim, they would send me and the chief medical officer an email that they were named in the claim. And, you know, that that was automatic, you know, just absolutely. You want clinical leaders who know, you know, who are going to know what's happening around. So, you know, you have somebody who had had had patient aggression, the clinical division chief or such would probably know about the program director for residents. Let us know let you know like Dr. Vincent. No, there was an event. Boom. These are the people who are involved. No judgment as to whether they need peer support. That is up to the person who gets the outreach. Nobody should be forced to be supported. And what you would think right is that people when you call them like a cold. So it's not a cold call. Really, it's an email and saying, hey, I'm reaching out. Give me a call when you get a chance. People do answer that email. And then you explain the program. This is part of the training. Explain the program on the phone. You normalize the outreach. You would think people would be like, what do you call? Why are you, you know, how do you know? No, people get it. You know, we understand this is, I mean, they're remarkably appreciative. Even if they say, I'm good. Thanks for calling. They're appreciative of the outreach. So again, it's the way it's done, but just getting, you know, getting awareness of the program so that those people who would definitely be aware of events will automatically tell Dr. Vincent and colleagues that this happened. I mean, you know, really tell you don't want to tell a whole bunch of people you want to tell one person is going to sign up your supporter. I hope that's helpful. I think that's very helpful. I mean, I think it's oh, go ahead. Sorry. Trumpin. Okay. Go ahead, Amy. I just had a question to follow. That's no. No, no. I was just going to say, I think it's really important that you normalize the outreach because I think, you know, it's culturally, um, each department, each division, each whatever is different. And so I think there's different thresholds for, you know, tolerability of such a program. I think, you know, depending on how much skepticism there is in it or whatever, there's going to be varying degrees of, you know, while you're calling me that can be quickly swaged by, well, this is what we do explaining the program moving forward. And I think if you, if you keep at it, then, then eventually you, you, um, kind of overcome that threshold. This is just what we do. Yeah, it becomes cultural. I have to say that even I think you'd be really surprised at even the, you know, most hard knows sort of like I'm fine and, you know, I'm perfect. When you do an outreach that's done in a very normalizing way, hey, we've this peer support program, we reach out to anybody in blah, blah, blah, blah, blah. You know, the thing, um, they're like, they, they don't get defensive. People really, really appreciate having this as an offer. Now, they may be different thresholds for accepting a peer support offer. And that's fine. You know, I think that is true. But actually getting the outreach. Yeah, people that they just, you know, it has to be done in a way that's normalizing and desigmatizing. But I think people feel like, you know, hey, that's great that there's a program. That's my experience. Somebody had a question. Oh, hey, it's Peter Weinstock from Critical Care and hi, it's good to see you. From the SIM program. You know, and listen, looking at your peer support principles, I can't help but see the correlation and the similarities with what we do in SIM. Um, in terms of other debriefing methodology specifically, um, psychological safety, reflective prompts, uh, non-judgmental environment, stances of curiosity, uh, and not certainty. This idea of loving the learner is very inherent in our debriefing methodology. And so many on this call, either are involved in that process or have folks in their divisions and departments who, who utilize that debriefing methodology. And I'm just wondering from your standpoint, I know you've had a rich history in SIM as well. Um, what role do you think we could play as sort of an army of debriefers at children's, um, to help in this effort? Both on the simulation side, it sounds like you're using SIM as a way to use, as a way to train and to uncover, but also just the debriefing expertise. Could that be leveraged in similar ways to help enhance the peer support network? You know, Peter, this is great to see you and, um, I, it's really bizarre what I'm going to say, which is that I've actually hadn't made such a strong connection between those, you know, doing the cause of sort of came to, you know, I sort of started the separate, but you're right. I mean, there, there's so much overlap. Um, so this is just as spontaneous response to that. I think we should leverage it. I think, um, I mean, the way I would leverage that. Well, one is, um, I mean, what if, as, I mean, you could use, you could use SIM as a way of as part of training, which is that, you know, there's a peer support aspect to like a very specific one on one. After a simulation of a, you know, of a bad event, right. So you could actually integrate, um, you could actually, you know, let people experience peer support after having done this for an error. And then we had that on to, uh, to the training. I think that would be incredibly powerful. We get people to, to really be comfortable with it, because it's so powerful. And of course, you're, you know, really wonderful, um, simulation, expert skills to do, to do the peer support. It's slight. It is a little different. I would, I would, you know, and I could, we could sit and think together about where you'd want to make sure that it isn't the exact same as debriefing because, um, I, I'm definitely aware that there are some differences, but the basics of it. Absolutely. So I, I wouldn't want to just tack it on without doing like a little mini thought about the differences, you know, what you want to do it a little bit differently. You know, the core is really the same. Um, and, and, and even if you decided not to do anything that I suggested, just because you, you know, you got the sim going is to make sure that, you know, at the end of every sim, you know, you say, I just want to mention these things can be true that it can real live. Remember, we have a peer support program. So, you know, if you don't get an outreach, this is the place to call, because these things can be, can be really challenging. They are for, for most of us who are carrying in compassion. Joe, thanks so much. I was just wondering, have you had the situation where someone from a peer support perspective? It has an interaction and then feels like the person in fact should not go back to work and how does, how does that type of situation handle from a peer support perspective? How do they enlist more help and what's the nature of how that progress? Yeah, good to see you. So that's a very fair question comes up in training really often. So I always address it, but it's, but the real answers like stay in your lane. So you really aren't in a position to know whether someone's, you know, impaired or, you know, should or shouldn't go back to work. I mean, you just, you don't know enough about them. This is like I said, psychological first aid, but let's say you have a sense that you're concerned. The first thing I would do is say that concern to them saying, I'm worried about you. You know, you've just told me X, I'm so glad you share, but I really want to invite you to think of taking some time and would, you know, just taking a break, maybe getting some further support, whatever it is, you know, depends on what the circumstances would be. And I would be glad to facilitate if you think you couldn't ask for that or, you know, arrange that to actually facilitate that for you if that's something you'd like. So you would, you know, really, really say, I'm worried. They do get to decide what they want to do. If you at the end of that, you know, session, or you're still really worried, of course, you would talk to, you know, the doctor Vincent or one of her colleagues and say, I'm, and you could start within an anonymously. I did some peer support. I'm worried about so and so. And so don't hold that where you alone. And then the question would be, you know, should somebody else do another, you know, an intervention. But I'm going to tell you it's a very fair question. And it's absolutely something that pretty much never comes up just because, you know, again, that peer supporter is not really in a position to make that judgment, I think. And so, you know, you would, I would try as hard as I could if someone said they were drinking some they found, but, you know, I would be like, you know, we have physician health service. Would, can I get you connected with them, you know, get this sorted out, but to, you know, to report someone. I think, you know, I wouldn't say you would break confidentiality for those things because you really, you're not in a position to know you're just not. What you're hoping, of course, is you've got a whole organization there and if somebody has impairment, I mean, it's really up to, you know, I mean, that should be noticed by, by people. But, you know, you try with that person and then you get help with the someone, you know, in the leadership position about, is there anything else we should do. I think you bring up, you know, just as the hours ending up, I think you bring up one of the most important points is, is in setting up a wellness program or a peer support program, know who your team is. And know what roles people play and who you can draw on in different situations, because these, these situations can, can feel daunting. Really quickly. And so, you know, I really appreciate you saying all that. We are right at eight o'clock. I cannot thank you enough for sharing your wisdom and your expertise and your time with us this morning. If people want to reach out to you. Awesome. Good. Happy. Thank you. Thank you. Yeah, please do. And I'm thank you again for, thank you, Dr. Vincent and the leadership and for all of you for the work you do and for showing up. Like I said, really appreciate it. Stay safe. Thank you so much. Bye bye.