Peer Support: Key to Sustaining Our Wellbeing

Good afternoon and welcome to today's education Grand round session we are honored to um to have Dr Joe Shapiro  present on peer support the key to sustaining our well-being we often hear of the importance of well-being for the  health care provider as Health Professions Educators you are not only responsible for caring for yourselves  and patients but also for role modeling well-being for your learners over the next hour Dr Shapiro will talk about the  barriers and consequences to health professional Educators not receiving the necessary emotional support and  highlight the key principles to peer support programs that can be designed to overcome these barriers  and now to share a little bit about our presenter before we get started uh Dr Joe Shapiro is an associate professor of  otolaryngology head and neck surgery at Harvard Medical School she is principal faculty for the center of for medical  simulation in Boston and a consultant for the Massachusetts General Hospital department of surgery  in 2008 she founded the Brigham and Women's Hospital Center for professionalism and peer support where  she served as the director for over 10 years in 2018 Harvard Medical School gave her the Shirley Driscoll Dean's  award for the advancement of women's careers and she continues to educate and assist organizations in developing  specific programmatic and educational approaches such as peer support disclosure and apology well-being  programs professionalism initiatives and conflict management and finally before I hand things over to  Dr Shapiro I want to thank her for spending her time with us today and she also wanted us to let you know that you  should feel free to post questions or comments in the chat as we go or unmute and ask your questions she encourages  your interaction so now without further delay please feel free to get started when you are ready Dr Shapiro wonderful  all right it's such a pleasure to be here I'm just going to make sure that you could see my slides so let's make  sure does that work yeah okay good good thank you um such a pleasure I um I am an educator  a clinician educator and there's I just really enjoy talking to people who care  about um about teaching and learning especially within uh the uh you know  within the healthcare profession so thank you for for being here and I want to thank um uh all the your leaders who have are  obviously incredibly dedicated and wise and um and care very much about you all  um and also I want to honor the fact that you all showed up that's it's a lot I mean to take an hour out of your day I  know you have other things you could be doing and I think it's just says a lot about you that you decided to take some  time for your own professional development um and that's a beautiful thing I think it's it's fun to learn but sometimes  it's hard to take time out to do so so thank you for that um I'm actually going to talk a bit  about culture um because I think it matters really uh intensely in what we're going to talk  about and um when I talk about culture of medicine I'm talking about you know not at your organization or mine or one  state in the U.S or even our country alone I'm talking about the culture of medicine in general and what I found and  I have great respect for I love cultural differences and there are many and I've had the opportunity to work abroad and  um and all over the U.S and I'm so respectful of differences um what always surprises me also though  is that um how consistent the culture of medicine is across all the organizations  I've ever had the pleasure of working with and um and we have some parts of our culture that are beautiful like just  to put one out there that we're all healers in some way right um and that's never going away like  we're always going to be oriented to Healing um I do think if we're going to get better and be better that we're going to  have to look at the the kind of the dark side of our culture and this is the one I want to talk about which is that for  many years I think our systems have treated us as inexhaustible resources ignoring our physical mental emotional  health and I also think that we've internalized this um and I think to our our detriment so I  want to talk a little bit about that because what what we're going to talk about today is really in um in in trying  to change this part of our culture um so I'm gonna focus on one of the  absolute hardest things that any of us has to confront and if you haven't yet  you will and if you haven't yet you'll also probably worry about it um and I'm gonna I will focus on um when  I talk about peer support I'm going to focus on peer supporting a colleague who's been involved in an error but  there's um so that that's what I want to say that I always like to teach to the hardest  thing and that's the hardest thing to to support for but if you can support for that you can support for anything  um but I just want you to you know individually reflect on thinking of a particular event or circumstance in your  professional life um and without saying what it is just because I'm what's most important is  really to kind of put out there what what is what's an emotion that you remember feeling um at that stressful  time um and what I want to say is I'm going to ask you to put it in the chat I can guarantee you that nothing you say will  be unique to you in the sense that these emotions tend to be really um you know very constant to the kinds  of challenges that we we meet in in our in our profession so just you know what  what kind of emotions do you remember feeling and you can say what happened to what the event was um or you don't have to but um yeah just  welcome in the chat thank you sadness grief loss embarrassment um for sure  um yeah really really these are critic tense yeah um and maybe even fear you know like oh  gosh what's going to happen is especially if you're if we're talking about any adverse event or bad outcome dread  um yeah what's going to happen next wanting to run away feeling incapable having questioning our own competence  um anger fear why me for sure again depending on on the event guilt for sure  okay so thank you for answering that and I really will tell you that um none of  us is unique in this and I think knowing these are shared emotions is really helpful  um so when we talk about peer support um I want you to have the idea that peer  support can be supporting a colleague in any of these stressors like an adverse event sometimes Adverse Events are due  to errors so those as well Communications with patients after Adverse Events  um how to help with disclosure and apology just emotionally stressful patient outcomes things we see that are  just devastating that have nothing to do with our care but just the circumstances of a patient's life being named in a  lawsuit some chronic stressors certainly coveted was a huge one being bullied at  work patient complaints being reported to the board um I'm sorry to the National  Practitioner database or the board and then you know as probably if you've read  any literature on this you know that the incidence of patient aggression to Health Care Providers is increasing so  any of those moments are really highly stressful um so this is sort of Broad in terms of  what we can do peer support for so you really answered this um which is  focusing on an error I think some of the emotions that we all tend to have and I  want to delve in as I said to use this as an example of where I think these stressors really uh come into play and  what we can do about them so um uh what I'm going to talk about are the  uh very common emotions that people feel in in the particular stressor of having made an error  um uh and that that said we know a lot about that but what anyone feels  individually at that point is is them I mean we can't say oh I know you're going to feel shame or I know you'll feel  tension or what have you um but we will you know sorry so it's  very individual what people feel and yet there are some very common and known reactions and that's what I want to go  through with you so people feel sad as was mentioned in the um the chat shame  um a shame goes from where you are saying I feel really bad about this and sad about it and then you add on and it  happened because I'm not good enough I'm not a good enough physician pharmacist nurse whatever  um it can trigger self-doubt and imposter syndrome and it's pretty powerfully  negative feeling that that shame is so I was always wondering like why are we so ashamed and I really thought this study  helped me um see this pretty clearly um and it was where they looked at um the similarities between Aviation and  Medicine when it came to Terrors and um sorry and they found that both stress  the need for Perfection and a deep perception of personal and vulnerability so I'm gonna I'm gonna translate this  because I think it's very real to most of us we have been taught and we're taught for  forever that the way to keep patients free from harm is to affect is to expect  error-free performance from ourselves and each other all the time right which would be great I mean we all want zero  harm um and the thought was to get there you just have to not make any errors there's  a big problem with this and that is that's an impossibility humans are humans we make errors actually  predictable rates you can't change outcomes by preventing all Errors By requiring zero  errors there are many ways that we could and should and do prevent harm to patients but it will never be by  eliminating human error because we're wired to make errors um and yet do we really internalize that  I think we don't and we think actually we still should be error-free now the  way we should be working instead of saying nobody should ever make an error would be okay let's each personally  decrease the chance of our making errors it'll only be zero but we can decrease it by being well rested getting help  when we need it practicing what we need to practice reading what we need to read all those things really important  um and Our obligation to do in addition we should have a system that's set up to  prevent what naturally any errors might happen just because of chance from  reaching the patient and the third very important thing is we should actually  look at the system and take out or change the ways of the system makes us  puts us at higher risk for making individual human error like asking us to  see too many patients or cover too many patients those as an example are not giving us time to sleep and recover  those are systems issues that set us up to make more errors so those are all the things that need to be dealt with  personal and systems but that's very different from what I think we feel like which is this as it says in the study  this perception of uh that either the need for Perfection okay um so you know I I I'd like um to ask  you a rhetorical question which when I talked to you know a big Auditorium full of people I just go could you please  raise your hand if you've never doubted yourself which was this slide here um and of course nobody raises their hand  because I don't care how smart and wise and experienced you are we all have  moments of self-doubt and they often come into play after we we have made an error for example  um and I just want to say that I think that's healthy to a degree that we think oh gosh you know should I be doing this  um at this work but then I think we need to put it in perspective saying you know we're human and we do make errors  um so I think also Society set us up for this false expectation in some ways like  this whole Healthcare hero thing which sounds really good and I think it comes from a beautiful place  um it's a double-edged sword it feels good to hear but also I think it sets us up to feel like you know somehow Heroes  with our capes you know are don't need the same amount of sleep are are capable of just you know like during covet of  just doing you know being assigned to a different place and even if you didn't know what you're doing um and you know just seeing a whole lot  of death uh without you know it affecting us and that's just wrong because we are human and we're not you  know we're not uh caped Heroes um and so I think we just have to be careful about societal expectations and another  example of that is there's a children's hospital where they're sort of tagline on their Vans  like their banners outside and inside their Hospital says until every child as  well okay now that's crazy because every child entering a children's hospital is not  going to be well that's that's an unreasonable expectation to say that we can meet that expectation so I think  some of this does come from external that we then internalize um I think also the culture of medicine  we place a high value in getting you know putting our head down getting our work done just doing your job it's not  supposed to hurt you know walk it off we can usually fix things and these are times where we may not be able to  um fear somebody mentioned something close to fear um what are we afraid of anybody can you  put in the chat like what are we afraid of after an error what are the kinds of things that might go through our mind oh  gosh I am worried about anybody or you can come off Mike to I mean off mute too or or the check what are we  afraid of yep repercussions to us to the patient  um not meeting the standard of care um will you know maybe we'll harm somebody else people questioning our  abilities absolutely these are all fears um anything yep losing our license so some kind of negative job consequence  what else are we afraid of after errors like it's kind of the elephant in the room but I think everybody worries about  anything you can think of  sued yep absolutely not unrealistic as a as a fear anyway  um so all of so you know I mean all these things can swirl through our minds and I want to unpack um one of them in  particular um and that is um this idea  um you know that and people sorry I want to unpack it in the sense that um we're afraid of all these things um  and then somewhat kind of frustrated and angry that um we are being subject to a certain kind of uh reaction that doesn't  seem consistent with what we're supposed to be doing so what do I mean by that did you all um at your organization did  you get the memo that your whole organization is done with shame and Blaine no right no organization anywhere  sent out a memo saying okay you're done you're fine you're good um it's absolutely  um something that we want to move on from shame and Blaine actually makes the system less safe but we've been doing it  forever and so we want to shift to uh personal a safety culture which is where we do have  personal accountability and systems accountability as I mentioned earlier but with the eye of not shaming and  blaming because that makes the system less safe with the with the goal of learning so that we don't do this again  to any other patient but you can't just go from a you know decades and Decades of Shame and blame to another you know  to a different Culture by just telling people that we are so um I want to sort  of show you the way to think that how we still are in the shame and blame this was a really interesting study where  they looked at the referrals to women surgeons after they'd had a patient death and the referrals dropped by 54  where if a male patient had a male surgeon had a patient death there they  really didn't have much effect it didn't have much effect on their referrals this is obviously unconscious bias  and that's I think what the point of the study was to see if that was true but I put it up here um just to say that it's  just a specific example of where we do judge each other and the person in the chat who said we're you know kind of  worried about what others think of us our colleagues or you know repercussions but um uh that's real because we tend to  judge in this case it happens to be skewed against women but I think generally it's not it it's we're judged  we judge each other and the only way to move beyond that is to recognize that we're being judgy and say oh you know  what I think you know this person's really smart and committed I wonder what did happen maybe there wasn't even an error and if there was you know it was  probably a reasonable choice at that moment so but this is why I think I mean  I put this up to say it's valid to worry about what we think of each other and then I put this here to say look every  time any time there is a um adverse event you know with a significantly bad  outcome many of these uh processes depending on where you live um will come into place like Eminem root cause  analysis uh the Department of Public Health sometimes comes in to investigate or the board of registration in the  Netherlands where I've worked a lot around these issues is the inspectorate in the uh in the UK it's the Royal  College we've got the court of law there's also the media these are things that that are triggered often when  there's a bad outcome so I think you could see that these could be done in  age systems in a safety culture fashion where we're trying to learn but often  they're not often they're done in a shame and blame way and what I want us to be empowered to do  is to say well we're going to change not that we're going to do not do these processes but we're going to change how  we do them right we can we have some effect on how is Eminem conducted  um especially as as Educators um and can say like this is not you know we've got to make this an educational  opportunity not a shame and blame opportunity um and same thing with you know the the  people who do these investigations and I would say even the court of law court of law is Shaman button for sure they're  not interested in learning when you're in the um the the court system in the U.S they're interested in finding who's at  fault usually one provider maybe several and then punishing them  so there is an alternative and it's well researched and it's been done lots of places I hope you all are either doing  it or thinking about doing it which is developing a communication resolution program where we're very transparent  which you should we should have been anyway with patients about what happened um and then if it's a if the care is  unreasonable that is outside of the standard of care than offering financial and  non-financial restitution okay it's been done it's cost effective but it's also  the right thing to do so even court of law we can do something different  um all of these emotions can lead to uh isolation and loneliness and those states are very  um well they put us at risk or acute and chronic stress to feel isolated  so I think you'd agree with me that look these reactions are normal we  wouldn't want to train a generation of of clinicians who were like meh it's not my  fault things happen hey whatever um well you know actually we we suffer  because we care um that's appropriate and many times we move through these these acute traumas  for us um and and recover and learn but sometimes recovery is thwarted and this  can cause significant harm and I'm just going to really briefly show you some studies there's many more you may know some more that shows some of the things  for example with this stressor of error of the things that can happen and this looked at  um depending on what kind of error what were the effects on um and you can see very high high  percent of of uh clinicians or this was that specifically a physician study  increased anxiety about future errors a decrease job confidence we talked about that decreased job satisfaction  sleeplessness harm to professional reputation even in the blue lines when  that error didn't even reach the patient that's amazing like one in 10 people felt you know they had a harm to  professional uh reputation even when they had a near Miss that's that's a lot and then you know 15 people a percent uh  notice that if there was serious error so you can see that there's a lot of people suffering  um we did a study looking at a hospital in the UK versus when I was at the Brigham our Hospital nurses and  Physicians on both sides of the pond no difference between the four groups but almost a third had some negative effect  uh negative impact on these domains we know that burnout and depression are  independent uh predictors of having made a recent major major medical error okay and so there's a cycle like if you've  made an error you have a higher chance of being burnt out if you're burnt out higher chance of making medical error okay  um very sadly making error increases more than doubles the pers chance of  suicidal ideation that's really devastating and it's probably true with completed suicide  that there I mean we know we know I think you may have heard of but I can tell you I know of examples of  Physicians who've died by suicide after errors because they just couldn't take the shame and all the other uh negative  reactions so we have to do something different so we did study uh several years ago where we looked at lots of  different stressors and this also happened to be a visit this one happened to be a physician study um and we asked lots of questions about  different stressors the graph I'm going to show you was an answer to if you were involved in a medical error where would  you want to get support from and 88 wanted to be supported by a physician colleague even though we had great  mental health professionals EAP employee assistance program the vast majority wanted to be supported by a physician  colleague and another study looked at what were the things that correlated with resilience after Adverse Events and  resilience defined as what uh as actually grow through trauma in this  case um this was we called this wisdom gaining wisdom instead of having it you know really crush us  um and one of the one of the factors was talking about it with colleagues so we decided we got to build a program  that addresses what we know from studies what do people want and so it's this  formal peer support so what what is that compared to these the other kinds of support on a spectrum one is informal I  bet everyone in this room the virtual room together has done informal peer support where you check in on the  colleague after what could have been a stressful event which is great and for some people that'll be enough but not  for everybody um they aren't really expecting you to you know list hear them say I'm falling  apart I can't sleep I'm I'm questioning my own competence um so for some people they're going to  need something more and that would be formal peer support formal peer support though is not longitudinal care it is  not a coaching or mentorship or or therapy or anything like that it is a  peer a colleague trained to provide let's say an hour ish conversation with  someone in acute you know experiencing a stressor that um uh that that the peer  themselves of course has experience which is with errors all of us pretty much and so  um that may be enough for some people but not for everybody and some people need and want further Professional  Resources like counseling the problem is there's so many barriers to accepting or  wanting or being able to get counseling um that one of the jobs uh that when I train peer supporters to do is to  destigmatize and facilitate referrals for further Professional Resources should the peer want them nobody gets  pushed into any of any support of any kind um so that's where formal peer support  sits within the Spectrum the principles of it you know obviously I mean I train people to do this and I believe you have  to train uh uh US non-behavioral Health uh practitioners and you have to train Behavioral Health practitioners too  because this is different from therapy um I mean the good thing about doing this as a surgeon is nobody thinks I'm  actually a therapist right like no mistaking that I'm not um and so you know this is these are the  principles which is giving your loving presence to your colleague uh in the setting the psychologically safe uh  listening of course and validating um but also using non-judgmental curiosity to really dig down as deep as  the person wants into what's bothering them and how to move forward the idea is  to get help them get started on a plan for their own healing  um I we use reflective prompts to check in on sleeping concentrating suicidality those sorts of things and explore with  them what are their own coping mechanisms and encouraging their adaptive ones and discouraging any  maladaptive coping mechanisms and then helping them see you know whatever the stressor is that it's a part of what's  happened to them and who they are but it doesn't Define them and then as I said connecting them to resources and  appreciating that they shared um the the problem generally with support and I we wrote an opinion piece  in the New England Journal um and my colleague Tim McDonald wanted to call it if you build it they won't come you know  uh but New England Journal doesn't think titles like that are funny we didn't even try actually  um the point is that many places already have support but it's not support that  gets utilized by many Healthcare practitioners so just because you have support in place and an organization  doesn't mean it's actually going to be utilized by the people who really need it and so we talked about what are the  principles that you need to do to actually build a program that can get people the support that they actually  want but for many reasons Agricultural and um and uh you know personal there's a  barrier to getting um this was from that other study which where if you want to support what would  get in the way if you would what are the barriers to seeking it and you can see you know no surprises I don't have time  to do it I'm worried about confidentiality um stigma from getting support and even  you know not being sure how to actually do do it so you have to build a program  that helps people these barriers be overcome and I think these are some psychological barriers  um about you know we have a culture of Silence which links isolation people feel they're the only ones having these  you know awful feelings our needs don't matter um self-care and self-compassion are  selfish I put that in yellow because I think we're taught that right and I  think there's more understanding now that the burnout literature has you know hammered this for us but that if we  don't care for ourselves and use self-compassion the problem is in the  moment may be fine but never processing some absolutely human emotions that we  feel given the things that we see in in our careers that's not sustainable that's and that's burnout material  um so ideally peer support programs are reach out meaning they um that you  actually know of an event that could be stressful whether it's patient aggression or adverse event or uh  litigation and someone is assigned as a peer supporter to reach out and offer support to somebody  um and they can easily decline it but you normalize it hey a lot of us find it helpful uh to have support in these  situations is that something you like to do um it's also important to have that's a Reach Out component to have a reach in  that's easy like it's really quick people know how to get it the support if they want it and I think  um you know waiting till somebody's stressed and you know really not functioning well uh is really wrong like  we can proactively say this is a stressful potentially stressful situation would you like support for it  um and then I think integrating this even if there's no formal peer support program what if all of us as Educators  what if in our daily lives or certainly at times acknowledge wow that was really  tough that patient asked that's when we were close to I mean the ICU or something could we just take a  moment here together to appreciate that you know how hard this is because we care  um and then saying you know we have there's lots of ways to get support encouraging people if they need it or  want it to get it um I do think that we have to show that  vulnerability is courageous and not weak right we have to model it hey  we will say this is stressful for me or I have a similar situation  um several years ago or when I was you know a resident and it really was hard  here's some of the things that I did to to move through it um but not say like you know have this  image of like nothing bothers me because I'm just so experiencing nothing negative happens  so as I said lots of ways at times that I think we should reach out and provide  support and make it easy for people to reach in I think that peer support is a um a  culture change tool right it can have us go from a culture shame and blame to  adjust culture or safety culture where we say no actually you did you know you  made the choice because you thought it was the right thing um I mean there are very rare occasions where we do punish people like if they I  mean to be extreme if they came in impaired right and you know harm to  Patient obviously that's different or they've made five um you know five of the same errors like  that's that's not shame and blame but we would say okay there's a problem here and it's not the system it's uh you know  maybe we need you need retraining or what have you but most errors that we make aren't human error defined by at  the time it seemed reasonable for X Y or Z reasons turns out it wasn't  um and we're gonna say no we're not gonna shame you we're gonna actually all learn together it goes from saying you  know you may this error because you're a bad position to it happened because  you're human and these things do happen and they feel pretty awful and we're going to work through them  um this expectation that nothing should hurt walk it off there's no crying in surgery for example and it normalizes  people feeling pretty devastated um it takes away from this sense of isolation because appear is connecting  with you saying hey I've been there how can I let's let's work together to help you you start to strategize moving  forward and it really gets us away from self-care is selfish which is something we talk about during peer support which  is hey you deserve to take care of yourself and to have people help take care of you because you're important  you're really important and you know on a meta level having your leaders  organize a grand rounds this or others that you do about well-being in particular says like the leadership  cares about you um this we don't consider this a waste of time we consider this essential  because we care about you and I think that's modeling this idea that you know having you be able to do professional  development or what have you is important because your careers you know matter and we want them to be  sustainable um I don't use the term second victim  um as you know that's was used a long time well it used to be used some people still use it I don't like it because for  one thing this is from an educator named Parker Palmer he talks about just general this is not going to do with  errors but that that we're you know the victimhood is sort of a passive stance that we're uh co-creators of our world  that which he sees as an awesome responsibility and a profound Hope for Change and in addition the Patient  Advocates I work closely with do not like are referring to ourselves as second victims any kind of victims when  we've inadvertently harmed them um what I want to do is I um before I  open this up because I'm really curious about where this lands for you and also open to talking about um related or  other things um I just I thought this tweet was so powerful to me it really resonated as  for the uh you know wasn't written for this but um I dream of never being called  resilient again in my life I'm exhausted by strain I want support I want softness  I want ease I want to be amongst kin not Pat it on the back for how well I take a  hit or for how many instead of hearing you are one of the most resilient people I know I want to hear you are so loved  you are so cared for you are genuinely covered I just thought that is so beautiful and  I also want to say I think resilience is a beautiful thing um but I will say that we need to take  back the word because I think it's come to mean to us in medicine hey it's on you if you just did your deep breathing  and you're training for a marathon and you're uh cooking your own healthy meals  and meditating a couple times a day well by gosh then you could just overcome these big stressors in your life and  that's not fair right resilience is one aspect of well-being and I'm all for resilience efforts but it can't be it's  all on your shoulders so I like the definition of uh resilience as being  um growth through adversity and the responsibility of that being on individuals on colleagues and even the  organization to Resource efforts to help us right and then also this is a little  bit of a side but important issue organizations should stop doing things that are chronically causing us  incredible stress and there are things that organizations do that they should stop doing that are undermining our  well-being and at the end of the day aren't even good for patient care like too much production pressure for example  I'm not saying your organization does this but many do and I think we've got to look long and hard about what  organizations their responsibility to stop things that are really undermining  our well-being so my point is resilience isn't a bad thing it just shouldn't just be on our own shoulders for this growth  through through adversity um so let me stop sharing um just think or I should say literally  not figuratively and um I'm gonna pause and I have a question  for you and and in parallel absolutely welcome questions um from you or comments so my question  is how does this land for you where does this sit with you  um I see there's a lot in the chat but that might have been from other things so I'm gonna shower you're gonna run this show but I I A lot of times you  know speakers say okay do you have any questions which is great I love questions but also like I also want to hear what about this year are you like  yes this is awesome what about it it's like no I don't know you know or have you thought of this or we tried that or  I don't like that or what have you so yeah you can you don't have to put it in the chat you can unmute  um and we'll have some more good old organized chaos in the conversation because I'm really interested in where  this lands for you and the last thing I want to say is if there are any related things that you know that you've been  told that I have expertise in um some in the intro that you want to talk a little bit about I'm happy to do  that too I'm really here for you um we wanted to you know start off with this uh conversation about peer support  um so here we go let's hear what you're thinking thank you Joe what a fabulous conversation uh the starter this is uh  when you say how does this land with you a lot of the things that you've said today I've heard expressed a lot through  our faculty um and we have some comments that reflect that in the chat uh so somebody  says you made the point that I was just going to make faculty um slash employee EAP is rarely used by  physicians and like it or not I mean EAP can be a wonderful resource right and it  offers a lot of um a great support potentially but I  think for some reason for lots of different reasons it's not used by physicians I I don't know if that's  because they see it as punitive or connected too much connected uh to  organization or what but do you have any comments about that yeah I do I mean I think um you know  thank you for highlighting that um and um I I when we started the peer support program when I was at the Brigham  um I worked really closely with two women in particular from EAP we had an in-house EAP some places you know  outsources but we even had our own in-house EAP and we knew from our own  you know looking at our our own utilization and I had from talking to so many people of different organizations  the physicians in particular don't access EAP um for certain things like definitely  for some things like Child Care issues or you know those sorts of things all all important these are really important  things uh for us to have resources for but there's something and you know this obviously we found this in our study  very particular about certain stressors that we experience and people you know  the health care providers want to talk to other health care providers who know what it feels like I mean and I've done  a lot of people a lot a lot of peer support and I've you know so I always ask like who supports you you know  generally in your life and you know some people say like well my spouse is really supportive but they don't really know  how bad this feels because they're not in medicine um so and it's nothing wrong with the  spouse right it's just this is a very PR these some of these stressors patient aggression  um you know being reported to the board you know making an error those things they're just very specifically horrific  from you know in in a in a sort of uh well a specific way and so I think  there's that is the biggest reason I think for sure um there's a other reason which doesn't  have to be there but um I think if it's not a fellow health  care provider sometimes people don't trust um you know things that are set up within an organization as to be safe but  I think it's more just you know people just say I gotta talk to someone who really has been there  um uh Dr Lawler has this hand raised right now Dan do you want to go ahead and just  unmute yourself yeah hey thanks um really uh appreciated  the the presentation and I think a lot of this stuff does land I'm an acute care surgeon so a lot of the stuff lands very  um very well your point about having you know well-trained peer support is also  very important so yeah I think that lands really well and the other thing I just wanted to say was I think you know you talk about  resilience you know the corollary to that for me is compliance right is that you have to be compliant with so many  things you know and yet you're supposed to be resilient and compliant and you're sort of like those two things feel  um at odds frequently so um yeah I just really appreciate it thanks yeah thank you Dan and I just  want to pick up on both things that the the last thing you said I haven't heard anybody say the way you did but that  that sort of tension between um if you're not compliant that really just means you're not resilient you know  right um and I you know like I could go on with you about this it's like um actually you know no that's just wrong  for you to be asking us to do that or I can do it but here's the effect it's going to have on me and my colleagues  and I think resilience has been used sort of as a cudgel um in that way um and I think again I  don't think people want any Administration or anybody walks in the hospital saying I'd like to just beat down the healthcare providers on the  team but it's things that happen unwittingly and unless we realize like ah this is how this is feeling and give  that feedback it's just going to keep happening so thank you for pointing that out um yeah I think you said two things with  the within the first point one is um there's there's certain people who  are going to be better at doing being peer supporters than others period they just are and I for my  um experience and I don't have an RCT to back this up but yeah it's I think it has a lot of face validity a a good peer  supporter is someone who is both a relational person like just someone who is good at relating and also you respect  clinically like it's just those two things sort of have to be there so um the and the last thing that you as I  don't talk about how do we make sure that happens is um they I think people need training  right because as a surgeon personally I go into everything wanting to fix it  like with my kids I did I mean it's like and it can be so misguided like no you  know yes my patients if they have his anchors they want me to actually fix it you know they don't want to just hear  how hard it is for them to not be able to swallow like I mean I will hear that but that's not why they came to me  um you know as far as what I'm supposed to do so when I do training and I do you know I don't I don't want to say like  this is the only way to do it because I have a certain program I've done it a certain way it doesn't mean it's the only one it isn't right but this is my  way of thinking as an educator um and as a clinician is you have to  train clinicians out of the fixing right but it's more than just listening and so  that's why you know I showed you like sort of a summary of what what I do in training is I try to help people use  these techniques of um of non-judgmental curiosity but also reflective prompts you know lots of ways  that are going to feel to like a behavioral mental health person is really much more intensely like well  what about this what you know invasive if you will uh then then they would be comfortable with which is fine because  we're doing two different things so I think training matters you know again that's my bias  um I am the trainers I'm gonna take it with the greatest fall is that you you got to get the right people in the room  to to do the training and then you gotta help them train them out of their natural instinct  um first it's just some of it their natural empathy you want to keep that of course and the way we try to select peer  supporters and this came from trial and error we used to do it was just self-nomination but the thing is some  people who think they're going to be good at this just are not the people you'd want so instead we when I help you  know help Lots you know over 100 programs um start you know Healthcare  organizations start these programs I I suggest they get peer nominations so  that explains what the program is um so it's like a program awareness and then they get to choose people who they  would want to talk to as trained peer supporters and then we train those people um so you know you put in a lot of a lot  of points in your comments I just want to pick up on them thank you so much excellent responses thank you Dr Shapiro  uh Dr Register had her hand up next  hey um my name is Anita register and I really appreciate this topic and what  you're talking about and I really love that quote you said too about resilience because I think there's this just kind  of General cultural thought that you're resilient if you hold things in if you don't shed tears  if you're not vulnerable if you take everything on and don't complain about  it and really I think that culture definitely needs to change and there  needs to be more openness about things being hard and being okay to talk about that being okay to cry about it being  okay to just be vulnerable and open about what you're going through and I  don't know if you've recently heard about the oncologists in New York City who  they suspect had postpartum psychosis and was involved in a murder suicide with her four-month-old which is just  absolutely heartbreaking and devastating but definitely just kind of another topic on  well-being and yeah and then with all the EAP stuff too and just kind of getting uh support too I think a lot of  it is also just time and like when you feel overwhelmed it's hard to also find time to  access some of that too well thank you know thanks Anita for  sharing that and I mean that was so tragic and um yeah I think that's  exactly what apparently did happen um and and we have of course  um you know a history in Medicine of really not recognizing  um providing uh uh support for any kind of mental uh mental illness and or  mental health if you want to say it that way um which is so to to ourselves right which is so ironic like there's  tremendous stigma just the fact that there's still I think it's like 15 state  boards that ask you for your licensure renewal and initial if you've ever  sought help for mental illness well it's none of their business there's nothing they should be asking about that and it  has stopped people from getting mental health support so you know there's a good National conversation about this  and trying to push those boards to stop doing that and say same thing with Hospital credentials none of their  business it literally is none of their business um it so they're they're these structural barriers there are these you  know stigma about well you're not supposed to you know have these problems and we've got to hit it I would say from  every angle for sure um and I I want to say also when you  when I when you just talked about that you know the other negative you know a connotation around resilience if you  think about the definition of resilience and there's several but the one I like is growth through adversity none of that  pairs with holding things in like how has that come to be thought of as  resilient and I like the way you said it which is like well you know we need to say though actually feeling feelings and  processing them is you know developing resilience it is growth through it  because you're not stuffing your feelings down which may work in the moment but it's not sustainable often  and so I think you know saying like resilience nothing wrong with the term it I mean we just have to re you know  redefine it for people and say you know this is what it means to be resilient is  include it can include processing your emotions um and feeling your feelings and getting  help when you need it that's that's part of resilience and then the last thing I  want to you know highlight which is um I think this issue of like actually  getting you know finding the time and the resources into you know personal to get help when you're in crisis or in I  call these you know these situations these stressors traumatic right is is a  big barrier and so the way I suggest people you know do a programs do peer  support is there's this proactive reach out so let's say you need a we knew  there was an event that happened in your you know in uh sorry what kind you're what kind of physician are you  OBGYN yeah it will be yeah um is uh somebody would be assigned and  I let's say as I and I would email you and I'd say touch base you know in the subject and I'd say hi Anita I'm  reaching out as a peer supporter give me a call when you have a chance you would call me I'd say I don't know if you know this but we have this peer support  program and we reach out to anybody and after any kind of um stressful event you  know like what happened a couple days ago and the reason we do is because I and every colleague I know has been in  something similar um and sometimes it feels really good to talk to a colleague would you like to do  that that is I call it like you're putting it on a platter for the person instead of like oh there's some number  if you really figure out you call and no it's like do would you like this and you can say no right but even doing that is  an intervention because you know now now know well it's there and the  organization cares they've actually resourced this there's somebody who I could talk to um I think that's really important I do  think I want to think more like you know offline for myself about about the you  know mental health aspect of you know of postpartum because I think it's you know it's a huge obviously it's just huge and  I just don't hear us talking about it much within this context so I want to be able to reintegrate it so thank you just  giving me that's really really helpful appreciate that thank you Dr music you had your hand up  next uh Dr Shapiro thank you so much for a wonderful presentation very comprehensive with lots of resources  really appreciate it I just want to make a couple of quick comments I think that you know when you talk about support for  people particularly for Physicians I think where some organizations get off track is that they start with what they  think Physicians want or need as opposed to trying to find out which Services  Physicians are willing to use and then making those things easier to access and  so for example in Virginia the Medical Society of Virginia started a wonderful program a couple years ago called Safe  Haven which includes some statutory protections for Physicians who seek assistance through that in terms of  confidentiality and so forth and they work with the Virginia Trial Lawyers Association to accomplish that so it's  no small feat what they did so now there's some really important Protections in place for Physicians now  it's been expanded to nurses as well as pharmacists for folks who seek services  and support of which peer support is a major part of this Safe Haven program  their statute or Protections in addition to the services themselves so we're  getting ready to do a trial of this in one of our departmental service lines here to see if we can study the  effectiveness of it in terms of are people willing to use it has it made a difference Etc so just a wonderful uh  emphasis you know I love our EAP colleagues but there's lots and lots of evidence that physicians in particular  will not seek out the services that they need from EAP so rather than always hitting that one resource I think we  need to broaden our approach to this and say what will Physicians actually use and then direct them to that the other  question that I really think is important is the resilience question I'm not going to repeat others have said but it's the canary in the coal mine  argument right I mean you can have the most healthy robust Canary that anybody ever produced but if you put them in a  coal mine they're not going to last very long and I think the cultural organizational aspects of well-being are  so critically important and we have to move on from this notion that people can  take care of burnout by being more resilient or being more this or being more that so I really appreciate the way  that you emphasize that thank you and just we're so happy you're here thank you well thank you enough that's great to hear about that program that's  wonderful um sort of on the other side of that I was doing um a peer support refresher for some  peer supporters in New York um through their medical malpractice  um group called empro they have had me train a cohort of Physicians who are  peer supporters and one of them was telling me last night that um when I was doing this refresher  training for them that New York just State just passed a law that would make  it well pass the law and then it was tried to be appealed but the appeal was shot down that is now going to make  anything that is discussed in Eminem not protected and not safe  um which is like apps what I was just saying is like that is the dumbest law I've ever heard I mean I'm sure there's  Dumber but that's dumbest I've ever heard it's like literally the worst thing you could do for safety is to shut  down Eminem um and and so yeah I mean um we've got we have to keep uh my answer  to that to them was like all right look um we can decide then what we're going  to do in response to that law we can still talk about anything we want in Eminem we can say we're just gonna you  know we're gonna still do the right thing we're going to learn from it um and you know what happens happens  um versus we're going to shut down because this is you know you know it will put us at risk of being sued it's  like I would still we still have to have Eminem and we still have to learn from these things morally we have to do it  and that came up with peer support years ago was well in Massachusetts peer  support and most States but not all is not actually technically protected and we talked to our Med malinsurers we talk  to our defense attorneys our Risk Managers and we all decided we're going to do it anyway we're going to do it  anyway because it's the right thing to do and the consequence is the risk of not doing it is huge I showed you some  data the risk of doing it is very minor I've never seen it come to pass to be a problem and we're not going to take  notes Etc so there's a lot of reasons that that actual risk is very very tiny and  more theoretical so again sometimes you can do the right thing anyway even if it you know it's not protected but I love  that you're you know that that Virginia is doing that um Safe Haven work I think all those things are fantastic thank you  for sharing that you uh it looks like as if we have  another hand raised and uh Dr Lawler posted in the chat  um that there's a great New York Times article about asking do you want a hug do you want to be heard or do you want to be helped  um and then Heather um lovely posted the link in there so you  can access it right away if you want to click on that link not sure who has their hand raised but  if you want to go ahead and unmute yourself in it yeah hi this is uh Dr bielas at the VA I just want I think Dr  music and I are thinking along the same train I want to thank him for bringing up the safe haven because my thoughts  were exactly what he was talking about and they were about the legal implications of having such  conversations with a peer as well as patient confidentiality so I'm not sure  we have that at the VA but I'm glad to hear that is in Virginia  so um thank you for that information appreciate it  yeah it's great if we can get organizations to change their rules and regulations and make things easier for  us and in the at times that they can't or won't or don't we can still say we're  going to do these things anyway we're going to do them we're going to make sure that they're accessible we're going  to make the risk really really tiny because we again we know the risk of not doing it so but yeah I'd love to hear  organizations that are trying to do the right thing best comment in the chat it seems like  we are really talking about formalizing catharsis recreating the self-narrative about what happened and why at each step  interestingly much of this happens especially at the resident level and  formally but often um that isn't the physical space for  this isn't the physical pace for which these discussions can be had safely and instead concerns of privacy Trump  catharsis great comment I also wanted to make a comment that anything any of the  resources that were accessible Heather went and put those the links to them right in the chat and we will include  those on our website with this presentation and any other resources  that Dr Shapiro has to share um this has been a great conversation today thank you all for being so  participative uh and Dr Shapiro thank you so much for inviting that discussion and really  um uh facilitating a wonderful conversation about this tough topic my pleasure thank you all for your presence  and also for all the work you do stay safe  have a great afternoon everybody.