Dr. Mark Albanese - Healthcare Provider Health and the Role of Physician Health Programs

I'll just for those who don't know me. And it is my absolute distinct pleasure to be welcoming Dr. Alvin Ease here to talk to us about physician health services today. He is from Boston, trained here for the most part, and has really dedicated his career to the people of this area. I met him through the Mass Medical Society and through my work with Mass Medical Benevolent Society, which is a charitable organization, and has been in existence since the mid-1800s. And in the charter, it seeks to serve physicians in reduced circumstances. And that's still the language, which has taken many forms over the decades and now centuries. And it's a side note. Dr. Mark Rockoff is the president of that. And I've had the pleasure of serving on the Board of Trustees for that for about 10 years now. So we have interacted with physician health services for many years and have been delighted to be working with Dr. Alvin Ease the last several. He graduated Harvard College in the 80s and then went on for a brief stint out of the city of Boston four years. Ticket is MD at Cornell. It came back to Boston. Did his training at Brigham and Women as well as the Mass Mental Health Center was chief resident there. And then went back to do a fellowship in addiction in the early 2000s at Harvard. He has had numerous leadership roles in psychiatry throughout the region. But it pertinent to us today since 2021, he has served as the medical director of physician health services. And I asked him to come speak to us about the role of Ph.S., the function of it, and where it can serve us as a community. So without further ado, please welcome Dr. Alvin Ease. Probably the most important thing we need to know about me educationally is I'm a proud member of the Boston Latin School class of 1979 site, really. And as you were talking, I realized, yeah, just about most of my life, I can look out the window here and pretty much contained in this area. It was born at the BI. So in any case, let's see. So thank you for the invitation. I really appreciate the opportunity to meet with you all and to meet with different groups throughout the state. And thank you, Amy, you mentioned the benevolent society. The benevolent society has been so, so real collaborators with us at physician health services, providing financial support for so many physicians. We, I'll talk more about Ph.S., but our oversight includes medical students and residents. So when people require evaluation and treatment, it can get really expensive. And the benevolent society is a wonderful partner. So thank you, Mark. I know you're watching. So thank you as well. So I want to just kind of do a quick trip through the state of our health as healthcare providers. And then talk a little bit about what we can do to help each other and talk a little bit about physician health services and what physician health services can help with as well. Do you know who I am? So just a little bit of background. And none of what I'm talking about here is going to, it is new news to anybody in this room. But you know, we've talked a lot about the pandemic and the effects of the pandemic. And clearly it's been a life changing experience for just about everybody in the world. But certainly in healthcare, prior to COVID, things weren't, they were already issues as you all know. Burnout was already an issue prior to pandemic. Certainly things were exacerbated by the pandemic, but they were already a lot of issues with us feeling stressed and challenged in terms of taking care of ourselves. And so what I want to get into a little bit is, you know, what can we do individually? What can we do together at least a little bit of that? One thing I like to add, because I think over the course of the last few years, many of us, and I certainly consider myself one of these people, kind of got tired of being told, you know, you have to take care of yourself. Yeah, I know I have to take care of myself, but there are things beyond my control that if they were better would allow me to take better care of myself. And I want to talk a little bit about that. And those remarks are particularly, you know, offered to people who are in more of a leadership role, because I think together we can make improvements in the system and PHS is certainly committed to doing that. So I want to talk a little bit about what we did see and just review as a result of the pandemic. And I want to focus on the so-called psychological distress. And so this was a survey that was done in April of 2020 compared to the same results in April of 2018. So obviously this was early on in the pandemic. And you see there that in the number of measures of psychological distress, and the prevalence of it had gone up markedly about three times between April of 2018, April of 2020. And one of the components of this was loneliness. And loneliness was associated with increases in depression. And depression is associated with worse, but the presence of depression is associated with worse medical outcomes. So chronic illnesses just pretty much across the board are more challenging to treat as a result of the presence of depression. So again, thinking about the fact that in terms of recovery during COVID, co-occurring psychiatric conditions were a risk factor to worse outcomes. So in any case, loneliness associated with depression also increased drinking, especially of the binge variety and disproportionately so among women versus men. And let's we forget that we were still in the midst of the opioid epidemic and still are, in fact, there was an increase in opioid-related overdose deaths on those have consistently been elevated, even now in this kind of post-COVID period. One of the sources that I highly recommend you're taking a look at is this report, Task Force Report of the Surgeon General, which was published about a year and a half ago. And this is the title of it. So addressing health worker burnout, the US Surgeon General's advisory on building a thriving health workforce. And this is aimed not just at physicians, but at everybody in the healthcare system. And so they first did kind of a, and it's strange for me to recommend a federal document as must read, but this really is, it is well written and it's very much to the point. And every page, you're standing there just saying, yes, yes. And much of it is geared toward what the system outside of individual healthcare providers can do in terms of improving the health of healthcare workers. So starting with the federal, state, tribal governments. And so I'm not gonna talk much about that, but just I think really kind of is a deep dive into what do we need to do to improve the health of healthcare providers, again, not just physicians. In their review of the literature in terms of kind of what what other things that we are dealing with disproportionately in terms of prevalence amongst us, you can read this list. I've highlighted isolation, keeping in mind this issue of loneliness and the impact of that. And this keeps coming up, by the way, in this period post vaccination, where we're kind of out of the woods apparently, everywhere I go, people are still talking about feeling isolated, feeling lonely, dealing with a lot of leftover psychological issues that in a sense got kind of suppressed during the kind of all hands, on-depth period that we went through there from 2020 to 2022, 2023. So isolation continues and I wanna come back to that. This is a survey that was done as you can see in 2021, again, all health workers, not just physicians. And it was basically a survey of, again, kind of psychological issues that people were dealing with. Again, I've highlighted the prevalence of this feeling of loneliness that the people have been experiencing. And I alluded to the, kind of the almost the direct line between feelings, psychological distress, particularly isolation and loneliness and increase in drinking and in, from young people with OUD, opioid use disorder, ongoing use, and the increase in overdose deaths. Emma Goldberg in editorial in The New York Times wrote this, addiction is often referred to as a disease of isolation. And overcoming that challenge has only become more difficult during a pandemic that has forced people indoors. In some cases to live lonely lives with drugs and alcohol as a way to cope with the stress. And indeed, we talked a little bit about loneliness and the increase in drinking. And during this period, there has been an increase in consumption of alcohol, not necessarily of alcohol use disorder, but of drinking and unhealthy drinking, really across the, across society in the United States. I already mentioned the gender disparity, women more than men, it's easy to speculate on why that would have been in the context of COVID. And in, you know, we talked about psychological distress and the connection clearly, people who acknowledged increased stress and anxiety, were people more likely to use alcohol or other drugs as a way to cope. And one of the, and this has come up with a number of physicians that we've seen at the physician health services, which is the working at home, part of their work during COVID. As one physician said to me, he said, you know, I didn't realize that I was increasing my drinking until he had a, he had an accident at home in his home office, which in some neurocognitive changes were what basically resulted in the referral to us. And so it was just in our kind of baseline assessment that we, that we noticed that his alcohol biomarkers were elevated. And talked to him about that. And that again wasn't why he was referred to us, but the way he put it and it kind of stuck with me was, you know, I didn't realize that, you know, we would typically have, he and his wife would have a cocktail at dinner. But that would be when he got home from the office and, you know, they'd have, they'd have a drink, they'd have dinner, they'd watch something go to bed and, you know, do the same the next day. But cocktail hour is, he put it started a couple of hours earlier because now he wasn't leaving his office and going home, he was in his home office, turned off the computer. And so the reason why I bring that up is because it's really, this consumption has been for a number of people really kind of insidious and not necessarily in their, their consciousness. And in, again, several cases that I've had the opportunity to be involved with, there've been some certainly negative outcomes, not workplace outcomes with physicians, but certainly things like, you know, accidents and things like that. So certainly something for us to pay attention to in terms of our own self care. And I'll talk a little bit more about self care. But, and I promise I won't preach, you know, the thing that, again, I think a lot of us have gotten really kind of tired of being told, you know, you need to take it, yep, I know I do. And we'll talk about that. But certainly being conscious of alcohol consumption is one of those things that I had to mention to people. Because again, it's not necessarily even, you know, particularly noticeable. And then you realize, oh, look at that. I don't feel so great this morning. So, anyways. Again, so that's alcohol drug overdose deaths. You know, I, I, I, I'm an addiction psychiatrist. I mean, that's the work I've done for the last 30 years or so. So obviously it was coming, you know, into contact with this every day. I think this fell during during the pandemic. I think the opioid epidemic kind of fell off the radar screen a little bit because we were dealing with, with the, with COVID-19. But the overdose, the risk of overdose death is still really elevated. You know, we had in this period 2020 to 2021, that's over 100,000. So for the first time during a one year period, we, you know, it was a, it was a six digit loss of life to overdose deaths. And, you know, much of this, as you all know, is, is attributable to the rise of the synthetics, particularly fentanyl and greater risk with co-prescribing of benzodiazepines or with the co-occurring psychiatric disorder. And we can talk more about that. And I, I mentioned, you know, opioids particularly here because, and we'll talk about physicians specifically in a moment, but certainly among, within, within the physician population, among anesthesiologists, opioids are particularly problematic in terms of what gets people referred to, to us, for example, to physician health services. Alcohol is still number one, right? It's the most prevalent substance that, you know, among the general population and similarly among physicians, just that disproportionately among anesthesiologists, opioids are problematic. So the relationship between alcohol and suicide is a pretty well researched documented association. Risk of suicide death, as it says here, is markedly elevated in the presence of a substance use disorder. You see that the number one risk in terms of actual substance use disorders is opioid use disorder, sedative hypnotics and frequently these are used together as the second most risky. Again, because alcohol is the most prevalent substance in society, it's accountable for far more suicide deaths than any other substance, but the risk for substance is higher with opioids and with other sedative hypnotics. So as I said, just a little bit about physicians specifically in terms of substance use. So we're probably a little bit higher than the general population in terms of the prevalence of actual meets criteria for substance use disorder diagnoses. So it's about 15% for physicians, pretty much across the board, a little bit less than 13% in the general population. So certainly comparable to what the non-physician population is experiencing. And then given that this is anesthesia, grand rounds, I just wanted to make the point as I already did that among anesthesiologists, the prevalence of an SUV is a little bit higher than it is among other physicians. And so about 18%. And as I already mentioned, OUD is, this is the, you know, you all are the one group where OUD is actually more likely. And we talked about drinking and the gender differences with the binging being more prevalent among women versus men. Among anesthesiologists, men are more likely to have a substance use disorder than women. And it turns out you are all are among the riskiest occupations in terms of work related injuries right up there with the three Fs of farming, fishing, and forestry. So something for us to be aware of in terms of supporting each other and certainly the rest of the healthcare environment supporting what you all all do. So this is my favorite quote from that surgeon general's report that I mentioned. And at one point they say we must shift the burnout, burnout from a me problem to a we problem. And it's a very important thing. And this is what I want to talk about next. And I'll talk about the me part of it. But again, I just want to underscore the importance of the collaboration at all levels of society in terms of supporting healthcare provider health. But in again, this is my, this is my, you know, kind of disclosure statement that, you know, again, I think we were led to belief for very long time that things would get better in terms of stress and burnout if we just take care of ourselves. And meanwhile, you know, each of us knew what a day was like and the self-care frequently suffered in the context of the, you know, of the just day-to-day routines that we're all in still do participate in. The second point here is a quote in my role at PHS, I meet with a lot of different leadership groups. And this was a quote from one of the DIOs who participates in a general Medicaid, a medical education committee that we host. She said, please tell them we don't need another yoga class and I already meditate. We don't need another reminder about the EAP, right? So we know about these things and many of us do these things. And so I'm not here to say you should meditate more. But I am here to underscore the fact that if you do do things like that, that's great. You know, we certainly are better off if we do take some time to ourselves or together. But I think that, you know, we need to enlist the rest of the healthcare system in helping us do that. And having said that, I will say that in the, in this report, in the Surgeon Generals Report, which was, there were 34 and a half pages of recommendations and again, starting with, you know, the highest levels of government. Only one and a half of those 34 and a half pages were aimed at what the individual healthcare provider, recommendations aimed at individual healthcare providers. And these are the five recommendations that they make geared toward us individually, but as you'll see, it's individually in collaboration with colleagues. And that's really one of my, you know, take home points here is that we do better when we spend time with each other and time that isn't necessarily like this Old Umburg, Glad you all came, but it's time where we have an opportunity to really talk about our experience. And, but so in any case, the five recommendations geared toward us individually and in working with our colleagues, first one is to label the distress when you see it, you know, to ask permission to a colleague when it's clear that there are, that they're struggling, you know, may I, can I just ask, you know, is it okay if I ask, how you doing, you haven't been yourself recently, is there anything I can do? So, and, and, and then staying connected, right? I mean, it really across the board. So not just people who are struggling, but, you know, I have a, well, I'll get to it, but, and, and so that's kind of being, being on the alert for it and somebody else, you know, reaching out ourselves, right, when, when, when, when we're having, you know, when, when it's just, it's a really tough time and you just need to talk to somebody. Also important is, and again, this is the surgeon general speaking, prioritizing these moments of joy. And I remember reading this for the first time and, and thinking, yeah, really what moments of joy? And the reality is that, you know, pretty much every day, there are these moments, and they tend to get kind of overwhelmed by everything, everything else. One of the things that I've done on occasion, when I've, you know, run teams and, and, and rounds has been to, well, particularly when I know it's been a really tough week. I'll typically start the meeting with, okay, I want to hear like one good outcome that somebody experienced this week, invariably, pretty much everybody despite it's being a bad week, is able to identify and enjoy together those kinds of, of, of moments. Again, it's easy to fall into this trap of the sky is falling and some days it, it really is, but, you know, one thing, Amy, I don't know if I mentioned it in my bio, but I'm also medical, in addition to what it do, a PhD, I continue to be medical director of a method on program, the North Charles program, which is affiliated with, with, with, Cambridge Health Alliance. And Tuesday happens to be my day there, so I was there yesterday. And I can't tell you how many moments of joy there are in, in that work. And there are weeks where it's just those moments of joy that keep me going, showing up every day, doing what I'm doing. And it's typically watching somebody really get the whole recovery notion and really makes strides and express their gratitude to us as if we really were. You know, I feel like I'm just an observer and a fortunate one at that. But in any case, those are the kind of moments that get me through the rest of it. They certainly do allude in its reports of the good health habits. And again, I don't want to spend a lot of time here. You know, those, I was going to say the big three. I've added alcohol to this. I don't think it was in the surgeon general's report, but certainly, as I mentioned earlier, it's something you need to keep an eye on, diet exercise sleep. One thing I think that, societally, we tend to fall into this trap of this kind of all or nothing. So exercise really doesn't need to be a marathon. I could tell you for me, it ain't ever going to be a marathon. I only run when I absolutely have to, for my own safety or the safety of people I love. But trying to work some of it, and you know, simple things. There was a study, I don't know, not that long ago, I think in JAMA, looking at the health effects of among healthcare providers of using the stairs versus the elevator, right? Something presumed as simple as that. Now, I will say this also, there are moments when you probably want to wait for the elevator, because it gives you some built-in downtime. So that's the other part of the story is, take the stairs, except when you need a little break, and you really want to, you look forward to the delay of waiting for the elevator. And then advocating, I'm not gonna talk a lot about this, but we know what the issues are that contribute to the burnout that so many people are experiencing, right? You know, there's been a lot of surveys, we don't need another survey, we know what it is, right? It's lack of control over schedule. The EMR, well, I don't need to say anything about that. You all know what the EMR is, and then administrative burden, over and over again, these are the kinds of things that come up. So in terms of advocacy and advocating together, because it really is strength in us, again, connecting, collaborating, those are the kinds of things really we need to continue to be advocating for. And the medical society, I'm happy to say, there's been this burnout, task force predating my arrival at the medical society a couple of years ago. And one of the priorities has been, probably read this in vital science. One of the priorities has been the whole prioritization process. And there's been some strides made with that. This was an actual text exchange that I had with one of my friends, a fellow physician, fellow psychiatrist. I realized I hadn't heard from him in a while, so I just texted him, how are you doing? And he said, again, that in connection, those little things are really important for people. I said, so, how have you been? I haven't heard from you in a while. And he texted back. I'm overworked yet feeling like I'm not doing enough. I won't ask you to raise your hand if you felt this way as recently as today, but I certainly have. I didn't have my response here because it was slightly off color and I didn't wanna do that at Grand Rounds, but you can imagine what I said. And then his response was, I'm glad it's not just me feeling that way. Now, again, isolation loneliness, not reaching out. You can end up feeling like you're the only one who is doing something wrong, right? How is it fit? I'm going 25 hours a day, and yet I somehow have this feeling, I'm not doing enough. And my experience has been that, I've been involved in conferences where part of the conference was dedicated to provider health, particularly physicians. And whenever I'm asked to do that, I always hesitate a little bit because I feel like there's not much you can really say that people haven't already said or thought about. But what I observed when I first started doing this after, and I took this job at Ph.S., is that just the process of labeling these issues and saying them out loud becomes a very validating process. And so, I've been in the midst of doing presentations remotely by Zoom and keeping an eye on the chat. And what happens in very, very is that people start talking to each other about, oh my God, I felt that way. Is anybody else feel? So in that case, it becomes a real kind of online support group. And so, I don't know, maybe this will turn into that at some point, but in any case, I just think that it's important to have those moments of validation. So as I said, most of the Surgeon General's report was geared toward the rest of what the world can do to help support our health. These were some of the recommendations geared toward the larger healthcare organization. And I like to talk about this at these presentations because invariably there are people listening who can take these things to heart, maybe move the needle a little bit. So, I won't read them, but this is all gonna sound very familiar to folks. I do think that creating the space, the time and the space literally for physicians and other healthcare providers to connect in the workplace, right? Nobody goes to lunch, right? And God forbid, we don't certainly don't do it together for the most part. So, I mean, that alone, having it be a goal of a healthcare system to say, listen, we want everybody to take this time and don't do it in your office alone, how do we rebuild that sense of community? And so I think that's part of the challenge. And my experience is when you do allow for that, the people will come out of their offices in cubicles and actually make an effort at connecting. I will say the medical size pretty good at encouraging this. In some ways, this underscores why it is everybody's job to be interested and supportive of physician and physician's health and healthcare and the health of other healthcare providers, right? Because in the end, everybody does better. The health of the citizens of the Commonwealth and Massachusetts better when we're doing better in terms of our own health. I bolded the lower malpractice risk. Clearly, that's an important factor. I didn't say it, but I do have a slide here that goes over some of the key facts of who PhDS is and I'll get to that in a moment. But we are supported totally by donations and two of the largest contributors to our funding are the two big malpractice providers in Massachusetts. So, Kreiko and Coveris and that's, they're great people. I enjoy talking to them, meeting with them. But beyond being great people, they also know what the data are in terms of the connection between poor physician health and increased likelihood of a malpractice. Okay. I just kind of end with a little bit about PhDS and who we are with the processes. And then we'd love to have time for you all to comment and ask questions. So, we are a fully owned subsidiary. I should put that last point first. I don't know why it gets this laziness. I haven't done it yet, but we're a fully owned subsidiary of the Mass Medical Society. 501-C3 subsidiary. And in the fourth point down, we're independent of the Board of Registration and Medicine. So, we're part of MMS. We are not a part of the Board of Registration. I bring that up because there's this kind of mythology out there that when you call physician health services, it's like calling the Board of Registration and Medicine. It's not. So, I said it. I won't say it again, but it's the RMS slide. So, we're not part of the Board. I will say this however, because this is also important. We have a really good, we being PhDS, have a really good working relationship with the Board of Registration in Medicine. And that's important because in the end, everybody wins if they trust us to do our job and defer to us to do the job we're supposed to do, which is to be the experts presumably in terms of what physicians need when they get referred to us. So, there is no overstep, there's no overreach, there's no trying to, you know, somehow influence what we do, how we do it. So, it's great to have that relationship. One of the things, I don't have it, I didn't write it down here, but one of the things that we collaborated with the Board on was updating the language in the relicencing and licensing applications. I don't know if anybody's relicenced recently. I did last year. And the questions, those intrusive, stigmatizing, shouldn't even be there at all, in my opinion, questions about health, particularly mental health and substance use. The Board has, and in collaboration with other boards across the United States, not all of the boards, but about half of them have improved the language. And it includes so-called safe haven clause. And what that says, and I haven't memorized what it actually says, but it basically says something along the lines of, you know, if you're in treatment or working with physician health services, you can check note to this question. And it's the question related to, have you had an issue that potentially, a health issue that potentially appears, you're a function. And so it used to be, you'd have to check yes, and then give an essay on explaining what that was all about. Fortunately now, you know, we've made some progress. And that was really led by the Board and they invited our work with them on that. So again, mission of PHS is to promote the health and well-being of physicians and Massachusetts. And physicians includes medical students. It includes MDs, DOs, MDs and DOs in training. So it's all physicians and medical students and no other healthcare providers, although the legislature in Massachusetts has just, well, not just about six or eight months ago, passed a bill that establishes a PHS entity for the remainder of allied health professionals. So, you know, dentists, pharmacists and nurses. For nursing, there is a, you know, there is a PHS-like body, but that will be now subsumed by this other health program. So stay tuned, you'll be hearing more about that hasn't been developed yet. Important, any conversation with physician health services is confidential and peer review protected. So again, not only is it not calling the Board of Registration, when you do call, we can't, without your consent, we can't even acknowledge that we got a call from you. So it might be that we are interested in talking to other people to gather kind of collateral information, but without a written consent from the physician who's coming to us, there's no talking to anybody. This next thing about identifying and assessing, I'm gonna just quickly kind of walk us through what the process looks like in a minute. This other point that, if somebody voluntarily, wants your science of consent and says, yeah, I really would like for you to talk to my chief, he has kind of a view on what's been problematic for me, and I think it would be helpful for you to hear from her. And then who we are is really a kind of a diverse staff of really people who've worked in the health care space. So there's several physicians, all of us are not quite full-time, and then several non-physician mental health professionals, social workers primarily, including one who used to work for the benevolent society, who's is a great resource for us. And we have frequently physicians have questions around where it's just really questions related to kind of bored, related matters or issues that have come up. Medical students frequently have concerns about things that have happened earlier in their lives, and we have a general counsel who's great at answering those kinds of questions. So we have a half-time lawyer to keep, I think she's going to keep me out of trouble, but which is a full-time job, but we only pay her for that. 30% of our referrals, our self referrals, little asteris next to that, it may be that the person presents to us, but it's only because the spouse has said something like, if you don't straighten out in this area, I'm out of here, so it's self referral with a little bit of outside motivation. But most of the referrals we get are not self referrals, and it's typically the healthcare facility. So a chair, chief, program director, DIO, CMO, somebody like that will call up and say, hey, listen, this is what we're dealing with. Is this something you think, PHS could help with? It's usually a really low bar to say yes, because people typically need, typically there needs to be a bit of a deeper dive, and I'll look at that here in a moment, in order to determine if, indeed, there may be a health issue that's driving whatever it is that's causing to stress either to the person or to the people around them. And these are the things that we're typically asked about. So concerns about substance use, behavioral health issues, single biggest group of people that we see are folks who have co-occurring substance use and behavioral health issues, which is no surprise, right? The prevalence of co-occurring disorders in both the addiction and the mental health population is very high compared to the general population. So co-occurring is an issue among physicians as it is among the population in general. People might refer themselves or be referred about neurocognitive concerns, other physical concerns sleep disturbance. There's been more than one physician where we end up suggesting a sleep study and lo and behold, they come back and they have sleep disorder. And then the growth business for us is this last area which is, I hate to even say it, the problem, I don't like the term of problematic workplace behavior. You kinda, when I say it, everybody envisions that thing that they've witnessed that work and so it's stuff that happens. It's not just, it's not just somebody gets it, getting irritable and yelling inappropriately. It's also things like not just being woefully behind and important administrative tasks because again, nobody's favorite part of the job. I have to say, when I ran the OPCI service at Cambridge Health Alliance, OPCI service at Cambridge Health Alliance, every week I was made to review these, the lists of people who weren't closing their encounters. And it never did occur to me that I should refer any of those people to physician health services, but it has occurred to other people to do so. So that's one of the pools of referrals that we get, although I think the capacity is building internally to address these things in a more effective way. All right, just a little bit about what the process is just to kind of demystify the process about what, so what happens? I refer somebody to you guys and what happens. So person calls, there's usually a between referral and intake is usually a bit of a triage process that happens with one of our professionals who takes the referral calls. Then we typically will meet with the physician who is referred and some of the times looking at that top path, the green path, some of the times it really ends up being kind of an infre, a consultation where the physician might call and say, listen, I, you know, I, you know, when I was in medical school, I was in therapy, it was really helpful for some stuff that I was dealing with that was kind of came out of my childhood, you know, now I'm in residency and I'm not in treatment, but I think it might be helpful and, you know, we heard that, you know, you might have some resources that might be helpful to me. And so, you know, we do, we, you know, we do a bit of an assessment and it, and there really isn't anything else for us to do other than to provide some resources and then kind of not have any further ongoing relationship with the physician. The more likely path is that lower path, the, I don't know what that is, yellow gold, but in any case, it's where we, we do more extensive assessment and usually, those are the situations where we will ask the physician for consent to speak to other, you know, other people and the other people may be colleagues, maybe spouse, maybe, you know, division chief, chair of the department, just to get a fuller picture, again, no conversation without that consent. We typically will get baseline toxicology. You know, we've had, you know, plenty of referrals where the referral concern is nothing to do with substance use. I mentioned that one situation with that one physician where the referral was for neurocognitive issues, turns out by the way, he had a subdueral. And, you know, once that was taken care of, he was fine, but what we discovered in the process was that, hey, you know, you're drinking at the very least is kind of unhealthy, even though you may not meet criteria for an alcohol use disorder. So that's what the assessment phase looks like. If we have to take an even deeper dive, we will recommend further evaluation or treatment or both with a program that specializes in evaluating and treating physicians. And this is, again, talking about the benevolent society, where the benevolent society has been particularly helpful and generous in defraining the costs because these kinds of interventions can get really expensive, really, really quickly. And so, you know, so in any case, that's what that's about. And then for some group, for about 30% of people who are referred to us, actually it's probably more like 35, 40%, we would recommend an ongoing monitor and contract, I spared you that slide that lists all of the various contracts that we have because there's not enough coffee in the world to keep you awake during that slide. So I've spared you that, but there are ongoing contracts typically around substance use and mental health but also around kind of the problematic workplace behavior that we will enter into with the physician. So in the end, about 30% of the physicians that we see during the course of a year will end up on one of these contracts, three year substance use, two year behavioral health or one year, what's called occupational health. So which is primarily coaching for people who are having trouble, you know, playing well with others. Oh, I guess outcomes, I mean, this is, we're in the process, I'm on the board of the Federation of State Physician Health Programs and we're in the process of trying to get more recent data because this is a bit of a, you know, this is what is 15 year old study. But basically what it says is that, you know, if you successfully complete a contract with a physician health program, in 16 physician health programs from across the United States, we're involved in this study, including hours, including Ph.S. here in Massachusetts. You know, five years later when you reserve these physicians, 80% of them are, and these are all people who were being monitored for substance use issues. I should say that. We're still in recovery and working. So which is really, it's a big intervention, but the payoff is really striking. Again, you know, I've been involved in addiction treatment for virtually the entire career and run programs and 80% is just, you know, is crazy good. So, all right, well, there's a couple of minutes, but I'll stop and see if you all have any comments or questions. Thank you, everybody. To That's a great question. That's an excellent point. You know, the time thing, I, we were having our own retreat at, at Ph.S. last Friday and, you know, some of our own staff were talking about how, you know, basically, I mentioned that all the physicians, none of the physicians are full time and a couple of them are really part time, like 10, 12 hours a week. And, and it's not going to be a surprise to anybody that they work, you know, two or three times that amount, you know, so as I like to say, the 40 hour work week is that's in the fiction section at the library because nobody does that. It's not just within, it's not just within healthcare. So, and the other thing I'll say is I think that, you know, I, so I focused a lot on what people get referred to us for, right? It's, it's substances, it's behavioral health, it's workplace behavior. You know, there was an interesting editorial I read. I can't remember where I read it, but it was a physician, somewhere in the, you know, America's heartland, you know, reflecting on whether or not it's wise to drink it all during the work week. And in the end, what he concluded was that sleep deprivation was probably had a more detrimental effect on his practice of medicine than, you know, having a, you know, a glass of wine at dinner. Now, you might argue, well, I'll be the wine is affecting this. I, we could debate that, but the bottom line is I think that in general, it's occurred to me that, that there are certain things we don't pay enough attention to. And, you know, I somewhat provocatively had a meeting of the board for FSPHP, you know, people were talking about improvements in biomarkers around alcohol. And I think that's really interesting and exciting, but, you know, I get concerned, I get more concerned about, you know, being 24 hours into a 28 hour shift and, you know, risk of impairment from, from that. So I somewhat provocatively said, you know, I think, I think I've worked impaired and everybody, the conversation stops and everybody's, and I said, then it's going to do with alcohol or other substances, but I'm pretty sure, you know, 30 hours into a, you know, I trained in the Stone Age, so we still did stuff like that. You know, 30 hours in, I'm pretty sure I was not as effective as I was at, at, at hour one. Yeah, you mean? So, so, but just to get back to, to that question, the, I don't know of any comprehensive, I mean, it doesn't mean that there isn't that. What, what I can say though is that as, what, what I am encountering is what you're talking about, which is a larger organization really seriously looking at this and figuring out what they can build in. So that gives me, that gives me hope, because there wasn't that kind of discussion just a couple of years ago. It was very much about what you need to do individually. So there is a bit of energy around that. Okay, no, that's fine. I know we're over time. So, what we thought've seen, what we thought of was just a big這一 new project. How is that even if we got the support we gave them? We back up through some surveys to determine if we could end up Physics爪. Yeah. Yeah. Yeah. Yeah. You bet. You know, it's interesting because frequently physicians that compare because of the safety sensitivity of our work compared to the aviation industry pilots. And so, at this board meeting of FSPHP, I said so how many pilots do you know are still doing 28 hours shifts? And of course, there's none, right? Because they're limited. But the thing that made me think about that was the movie, uh, Sully, I get the one about, you know, the landing on the Huts, East or Hudson River. And there was this scene where the flight control person who was in charge of that plane, when it fell off the radar screen, they basically took him away from the controls and so listen, you need to have, you got to stop working. So it sounded like kind of what you were advocating is people need a time out after some kind of every operative issue. Yeah. We attend the culture as you work through those things. In any case, thank you all very much. Thanks.