Enhancing Learner and Faculty Well-being Through Systems and Culture Change

Thank you so much Shari and um just a great pleasure to be with you I have to say I feel a little more ease today I gave this talk last night um at 5:00 and I said yesterday that that was the first time I'd given this talk I now this is the second time so I'm now feeling very kind of at ease that I I should be able to finish it on time and hopefully the flow will go well um what's different about it is um usually I focus in on um either undergraduate medical education or graduate medical education and this is one that kind of looks at issues across the the medical education Continuum and I hope if there are people here from other professions that the lessons I'm going to talk talk about here that I think you can kind of pick up from this presentation are really resonate are not distinct and and kind of specific for for uh medicine um at all so I always start with some kind of an introduction and and framing thoughts and I will do that here um that are kind of key things as I look at this issue of well-being and in medicine you know of course there's been a big recognition that the people are struggling and that we need to be pushing to promote um well-being um and interestingly I you know I've struggled with this word wellbeing and and really for a couple of reasons uh one is as I joined the ACGME and I was traveling around the country before the pandemic especially from residents but also from faculty and even medical students I was I was getting pushed back like don't talk to me about well-being it's not even possible we're working too hard we're underappreciated we're we're mistreated Etc you know and there was almost this kind of rejection of it and and you know I could understand that and and and I guess the second piece that I think is a little problematic when well-being is the target is I think it's led to some well-intended and I think important uh interventions you know that are focused on the individual things like um you know mindfulness and meditation and yoga and social events and those are all well and good I wouldn't stop doing those but they really aren't addressing the root causes of what is leading to distress and so I started coming uh saying do we need a different word and the word I landed on I don't know if it's ideal is really satisfaction that I if we focused more primarily on on helping people become more satisfied with their work setting with the school setting so that they show up each day excited to be there energized positive um out of that I think well-being could emerge the other which I'm not going to have a chance to talk about much today at all but is another feature of my work is is I don't think we talk enough um about how many individuals in medicine and health Care overall struggle with satisfaction with self-there are a whole group of mindsets um maladaptive perfectionism impostor syndrome feelings of inadequacy embarrassment or shame that can add to the distress caused by the environment so if we work more on satisfaction with work and school and satisfaction with self I think we'd be making more progress in in in in U achieving more well-being and in the work study so that's number one second is there's a tendency when I look across the country that there's a lot of people trying different things that I that I kind of characterize as treatments of this problem right there might be coaching there might be mentoring there might be peer support you name it people will try things um I think what's again great that people are doing doing that but I think sometimes we need to spend more time making a diagnosis trying to figure out what is the problem within this learning environment that we need to work on to improve you know and I think that there's a little bit in the well-being movement of this one size fits all you know and I've heard this from people like CEOs and others that like just tell me what to do and I don't think we really can because the fixes have to be responsive to the environment in which people are working and and you know even in one institution what is going on in Pediatrics and threats to well-being or satisfaction may be vastly are likely to be vastly different than they are say in neurosurgery and I would even argue within a pediatric department the threats to well-being for those in say Child Development versus those who are working in the Pediatric IU those jobs are completely different and again the threats to their well-being may be different so I think we need to have try to come up with Solutions and interventions that are more responsive to the actual environment and cultures that people live in and then that culture word I think there's now um beyond the focus on individual resilience um which is never going to solve the problem it's important but never is going to be enough um there tends to be a lot of focus on what I would call systems when looking at the environment kind of thinking of the workplace as a machine um so the result is is understandably heavy focus on productivity pressures documentation burden administrative burden frustrations with electronic health record all of those things that can can contribute to burnout understandably um and I would add to that though is some of those are going to be hard to fix some of them are going to be hard to improve productivity pressures I mean there's there's kind of an economic bottom line that people are are compelled to meet um EHR you know it feels like you know maybe hopefully AI will do something there but it seems like a lot of the changes have been incremental at best and while we need to continue to focus on systems I don't think we should be ignoring those what I think has happened is that we don't focus enough on what just culture what does it feel like to go to school in a certain place what does it feel like to work in that setting um and and that's something in kind of the third part of this talk that will really focus Fus in on is is is what can we do to think about culture and improve culture so those are the the kind of framing thoughts and what I'm going to talk next about is I really think it's helpful there are a bunch of different models that that you can use looking at well-being and improving workplace satisfaction um and and one that I've kind of landed on is is not one that I created but it's actually amalgam or a fusion of two other models um one by masle and lighter Christina masle and Al lighter who've done decades now of work in well-being and burnout specifically Christina maslac known for maslac Burnout inventory but I don't think she needs receives enough attention for what she's done to to explore the the actual causes of of burnout and then to that I add some factors from Daniel pink um book drive which is about motivation and and keeping engaged happy employees so I'm going to run through this pretty briefly and and it's basically six domains that maslac and lighter came up with and two more that I'll add from from um Daniel pink so this is mlock and lighters the first of the six domains is workload and that's again as I said what a lot of people focus on and it's important to say it's not just the sheer amount of work it's the nature of work is it repetitive is it inefficient are there barriers to it is there is it nonv value added is it could it be done by someone with a lot less training an important driver burnout but it's not the only one second one that they talk about is rewards and and when you think rewards a lot of people move to oh like find um uh salary and benefits and yeah salary and benefits matter but they are looking at this much more broadly in terms of rewards really thinking about um how how much do people feel appreciated how much do they feel valued before the pandemic I think I visited something like 25 academic medical centers in about 18 months and I don't I don't think there was a single institution I visited where especially the faculty especially the faculty that they that they felt like incredibly appreciated and valued um so that's I think a real Target an area for improvement that we could be working on that doesn't have to be expensive community and connection how much of a sense of belonging do you have do you enjoy the people you work with are there conditions set up that you can connect with each other and have time to have meaningful relationships a really important thing about community and connection we have to be very mindful of the fact that our experience of community and connection can be often profoundly profoundly influenced by our identity so there may be some who are in the majority who feel a great s of community and connection and others based on race ethnicity gender Sexual Orientation May not feel that same sense of connection and community so we have to be mindful when we're looking at that this factor is how does identity impact our ability to feel that sense of connection or Community autonomy you know to me the way I would put it is is how much um do you have a say in how the work is done um how much does your voice matter if it's heard at all when big decisions are made this was another one again as I was traveling around the country before the pandemic and continue after the pandemic um again I don't I think it's incredibly rare um the number of times faculty would tell me about big decisions being handed down on from on high often from the sea suite and the hospital or the medical practice um without any consultation without any input um and and they were often not great decisions and the second piece of pain that Associated was associated with it was it wasn't great decision but the symbolic fact like you didn't even care enough to get my input to ask what I thought would be a good solution is I think a a a a secondary hurt or hit that happens when you take away autonomy um um and and take away people's voices fifth when it's fairness are PE people treated fairly is there a sense of Civility within the organization and and I this is one where I have to say given kind of the historic inequities unfairness in medicine and based on you know race ethnicity gender Etc I don't think this is a binary where you go oh are we fair or not I think it's like the question is how unfair are you and how far do you have to move to get to a place of of Greater equity for all in in your um work environment and then the last one is values um how much does your institution live up to the values um that that it espouses and I have to tell a quick story I didn't do this yesterday but I'll add this in today which is um when I was traveling around I I often would would ask people um employees like what's what's your marketing like campaign what's what's the what's the catchphrase that you use you know for p on billboards and things like that and and um and and then I follow up like is that has it been kind of changed in some ways that that is rather cynical and I think my favorite one is there's a there's a an institution I don't know have to name it but in the Northeast where their catchphrase their marketing phrase was amazing things are happening here amazing things are happening here and the employees changed it too amazing comma things are happening here which I just love you know so so what that really indicates is there is a gap between like the outward facing of who we are and and what actually was going on how the sausage was made so those are the six um drivers of either burnout or satisfaction and I guess what I point out here you know back to what I said about work you know um systems versus culture i workload is the really the only one that's pretty much straight systems the rest of these are all all culture all culture and they're not receiving enough attention um across the board I think in Us in medicine and medical education okay to that I'll add Daniel pinks he just has two more that some of his overlap with mass and lighter but the two that were unique is one that he terms Mastery and I'm not a fan of that word but I use it here in honoring his work it's basically a sense of competence um you know our expectations clear is feedback given regularly effectively so that you can um improve but also feel good about your performance I don't think we still pay enough attention to to feedback and I and I I think what we should start to think of it as is not just something to improve in performance but something that has a profound impact on on workplace satisfaction and ultimately West well-being as well and the last one the of the kind of collective eight then is purpose or meaning which which I just think is so important and and we'll kind of touch on this later in my talk um you know if if you're in medicine and you don't have a are not kind of fulfilled by a sense of purpose or meaning I have to say you've you've kind of lost your way and I I say that without blame because there is opportunity every day within your professional work uh to find purpose and meaning and and to essentially be sustained by it um so something we we'll uh dive into a little deeper later on so those are the domains I want to just talk briefly very briefly about a potential process then you have the model and then the process and I think what we need is is kind of a different approach than what we're doing right now in well-being which is um in part kind of spurred by a research Paradigm which is like let's start a program and see what the impact is so let's start coaching or let's start mentoring or let's do you know this or that pure support and and measure burnout and almost always with those kind of studies what we find is you know at best modest improvements and burnout or Improvement in well-being um that are statistically significant but but ultimately not meaningful and so what I think we need to instead is a much more iterative process not just trying one thing at a time but trying a number of things and in this kind of continuous quality improvement kind of approach back to the idea of nosis we have to have I think much more investment in making the diagnosis and the process I don't think has to be expensive or labor intensive I've been working on this kind of survey instrument that I'm calling an environmental scan that looks at those eight domains that I already talked about and just on a liyer scale one to five you know how are we doing how are we doing on community and connection how are we doing on fairness um and I think the advantage of that kind of environmental scan is it's not a diagnostic instrument it's kind of a screening uh uh tool um to find out where are your strengths where are your weakness and it's really important I think to to highlight the strengths because sometimes I think there's so much of a tendency in medicine these days to just focus on what's wrong and we forget like there's stuff that's right as well so reminding people of those positives as we work on the negatives I think is an opportunity with that kind of brief um survey instrument that's not enough as I said that's a screening instrument the next thing is to go deeper a deeper dive through focus groups Department division meetings one-on-one conversations you know so if you find for example that there's a real problem with community and connection you need to have conversations with people like what's going on why do you feel that way let's get specifics about what's contributing to that Global feeling that we're not a lack of sense of community and connection and importantly in those conversations that should then lead to interventions too often I think interventions are are uh implemented by well-meaning people who are not really necessarily deeply connected to people um who are in the trenches doing doing the actual work so that deep dive I think is is vitally important and then of course it's interventions you know um to to that are based on that kind of diagnostic process and then followup assessments you know continue to track this you know does the environment seem to be improving does that correlate or produce improvements in well-being so again this doesn't have to be an incredibly elaborate or expensive process um but one that I think is just vitally important if we're going to kind of come up with more effective interventions to enhance well-being so next segment is I'm going to talk about um work that I led uh that Shari alluded to at St Louis University School of Medicine um in terms of trying to improve their student mental health so um interestingly and I'm going to try and tie this together a little better than I did yesterday which is I I didn't have that model that I just described I was just kind of flying by the seat of my pants at that point and after I describe the interventions we'll return to that model and say ah how well did it hit each of those kind of eight domains in terms of this intervention so back at St Louis University I joined the the faculty and administ ation 2004 and uh as associate Dean for curriculum no background in well-being no interest in wellbeing at that time around 2007 I was starting to read work that was coming largely out of Mayo Clinic lahti Derby and others um that were showing these kind of very high depression rates High suicidality rates High burnout rates in medical students not just at Mayo but at at like five or seven um medical schools in the Midwest mostly in Minnesota and and I'd been at St Louis U for several years and and I looked at our students and I'd had this approach of like engaging with students and listening and trying to make change and create this kind of nurturing trusting environment and when I looked at the students then I was kind of like it seemed inconceivable to me that large numbers of them were depressed or anxious you know I knew individual students who struggled certainly um but the idea that you know like 28 8% or more might be depressed or that 11% might be suicidal or something like that seemed completely impossible and my supposition was like maybe just being nice and supportive to medical students was enough and we did something that was really important though is we didn't trust that we we decided to survey the students to look at rates of depression and and anxiety and and I have to say I have to admit this which I mostly did it to kind of demonstrate that like this was a way to like we'd had the answer at St Louis University and what became abundantly clear immediately was that we did not have the answer at all so these are we had two Baseline stat um um cohorts before we started the interventions um and this just shows their num so we have an orientation end of year from first year medical students end of year first second year medical students using a very well validated um uh instrument um that measured symptoms of depression these were the findings and and generally what most people would say with these screening tools is once you have moderate to higher it's very likely pretty well correlated with actual depression so you look at orientation rates are quite low um and then at the end of this the first year they more than quadrupled and then second year even worse right so are these were the same kind of findings that that L der was Finding at Mayo in her studies anxiety even worse medical students start um school with more anxiety than um you might see in the general population early on you know they're were worried what's med school going to be like um but it got much worse so a majority of our students at the end of the first year and at the end of the second year a majority of our students had significant symptoms of anxiety and probably if they saw a therapist would be diagnosed with an anxiety disorder and so so I will never forget when I got these results I mean when you look at results like this and the depression findings too the only conclusion I think you can make is we were doing this to them we were doing this to them and as associate Dean for curriculum I was ultimately responsible and so I I said like I this is not okay yeah this is unacceptable and we that day really started a push to say what can we do about this and the process I'll just say briefly was not only inmed informed by these results in that same survey we had questions that said like what are the most stressful things in your experience what are the things that are causing the most distress and I'll just say the top three that we found in those surveys was the amount of information that we were teaching the level of detail essentially that they had to master in the basic science and uh courses or pre-clinical curriculum the amount of time spent in class and then competition for grades back then we had honors near honors past fail and and which a majority of schools were graded at that point only about 35% of schools uh didn't have grades in the first two years and that's changed dramatically so we started on this process and and it was kind of a a a simple model that I constructed at that at that point which was really as follows three components one is that you know this was a largely an environmental problem so let's lead with environmental um changes and it was essentially what can we do to reduce unnecessary stressors or eliminate unnecessary stressors and then enhance the learning environment that was what we were going to start with second though is you know being a doctor is stressful med school is stressful life is stressful we thought that there were ways evidence-based ways that we could increase students abilities to deal with stress you know with a very modest well-being curriculum and then third that I kind of alluded to before is is I really felt like if we could help students Find meaning in their work somehow in their studies um that that would be protective for mental health so that was the model and then basically here were the specific interventions so in 2009 um we switched to pass fail grading in the first two years we cut the curriculum by 10% meaning every class had to give up 10% % of their time conent with that was that we um um ask faculty and course directors to reduce their content by 10% not just shove all of the same content into less time that resulted that cut in class time resulting in the development of one full day every other week for elective activities and just time for themselves and then we also kind of developed them these longitudinal electives and and what we call kind of them based learning communities uh around things like research and service and well-being and international Health Global Health um that students were kind of self-organized and ran themselves so that was that was kind of step step one the next year we did this very modest resilience and mindfulness curriculum for our first year students that was largely focused on giving them skills to combat mindsets like impostor phenomenon and and maladaptive perfectionism and overcome feelings of kind of inadequacy embarrassment or shame that might be Associated if with you know performance that they you know wasn't up to their usual um following year we made changes to the human anatomy course I think this is something we don't recognize enough in medical education and in education in general the ability of one course to cause significant distress even in a very supportive environment and that was the human anatomy course it was the first course in the in the first year um the first exam I'd say at least a third of the students were within five points of failing uh the exam when like welcome to med school they probably had five to six times the failure rate as any other course in the first two years and the level of detail and the pressure these students were was on were under was just tremendous and I'll just say kind of unconscionable um as a associate Dean for curriculum I had no power to change this but ardan kind of stepped in kudos to him and and told the faculty told the course director you cannot teach this in this way you you need to change or I'll find a new course director and so they changed and and what I what I always say is that you know they changed from just an extremely toxic course to a moderately toxic course but that was enough that was like it didn't it wasn't a cakewalk it wasn't just like wonderful experience for people in terms of the the over all but is good enough that I think it had a huge positive impact on on the first year students and frankly the other change we made is rather than it being the first course as soon as medical students came in it was the second course so that students had the opportunity to work with a faculty member course director who was just much more kind and supportive and eased them into the medical school experience the next few I'm just going to run through very quickly just because the details don't matter that much change to True pass fail in the first years I don't know how many schools do this many vast majority are now past fail but many schools I still think use performance in the first two years um for two things one is for um determination of eligibility for AOA uh um Honor Society and second they'll often report to residencies where somebody what quartile um person uh um uh landed in and terms of the the pre-clerkship curriculum um you know first second third fourth quartile in terms of academic performance we remove those and and basically then there there we reduced all incentives to chase scores to chase grades um following we offered confidential tracking of depression and anxiety um so that uh um those who screen positive uh could be seen by therapists U no obligation to um and then finally we did Focus support of second years in the run up to step one which I think is still a significant stressor but back in the day was was even more so because it was a a scored exam that um had a big impact on you know residency ranking back then so those were the interventions I should note here what's interesting about this um we didn't have to blow up the curriculum we didn't have to change the way we taught tremendously um yes there was effort in reducing details and coming up with new schedules um but the overall cost for all of this was less than $33,000 a year and and um most of it was just food for meetings so to me when I look back at this I think it's really kind of remarkable to realize how little this kind of intervention cost so those were the interventions what were the outcomes we had two Baseline classes I reported and I'm not going to give you all of the data of the intervening years because it just each year got better and better and better and then this is the last year that I was at at St Louis University and see what you can see is the first year students you know I'm just going to say depression rate in terms of ease of conversation a depression rate dropped from 27% down to 4% second year students from 29 to 35% down to 6% anxiety very similar um uh anxiety levels dropped from well it's dropped at orientation because I think students were hearing like hey it's not bad here you're going to you're going to have a good time here in medical school and and um but then the drops in first and second year students was was dramatic with the first Year's dropping even Bo below Baseline and the second years um right before they went into their step one study where I think anxiety is actually an appropriate reaction still much lower anxiety rates that they had um than the Baseline studies and and one thing I sometimes say I don't know that I say with a smile on my face is looking at these results I think it is very possible that you could say for the first time in medical education history that the first um year of medical school was therapeutic for their mental health which is just pretty striking that they actually had mental health profiles as a class that was better than when they arrived which is pretty extraordinary particularly because we still did bad things to them we still it was still probably way too demanding but we did enough to just have a pretty remarkable improvements in in um mental health and well-being um one other way to look at the data that I have to just mention briefly is you know the interventions really could have had an impact on two ways which is to take those depressed students and anxious students and and who were struggling the most and make them feel better the other approach or the other outcomes could have been that everybody uh felt better that there was basically a a a shift of the entire curve to the left and what was gratifying to see is that ladder is what happened so you see these blue bars are the ones for depression symptom scores um pre-change the baselines that we talked about and then the red are ones that was the class of 2018 the most recent class or the last class that got these changes and what you can see is the the blue bars that are at the top of the range disappeared just the really high depression scores just disappeared um but what you also see is the number of students with really low scores for depression jumped dramatically and what I would say we didn't have a measure for flourishing at that point but I think our outcomes were not just that we were helping our students avoid mental illness that they were actually flourishing they were actually many of them were thriving um uh in in their studies and their experience of medical school so those are the findings that we had and one of the questions I had at that time though is there was a big well-being push that was already starting and and like maybe everybody's getting better as they're working on this well-being thing but we were lucky enough to have these kind of external benchmarks which I just want to go through quickly so that you can see no this was this was unique to St Louis University so there's a double AMC year to questionnaire um these six domains the top three higher scores are better the next three lower scores are better so what you can see emotional climate student faculty interaction quality of life slooh was dramatically better than the national mean on on all of those perceive stress disengagement exhaustion really dramatic differences in our scores much better off than the national average um the other thing that was interesting in that AMC year 2 questionnaire is they ask students how much sleep they got and how much time they spent in class or studying and our students reported getting half an hour more of sleep per night and spending an hour and a half uh less time in class or studying per day compared to the average medical student so when you think about that hour and a half per day o over you know weeks and weeks and weeks these were probably resulted in basically a hundreds of hours less spent in class or are working to master the the kind of um uh material in the pre-clerkship curriculum and so one of the questions people might ask well oh my God they're not studying as much they're engaged in all these activities they're they're taking care of themselves they have all this time off um performance has to drop right performance has to drop there's no way they could perform as well and that I'm sure is what you're thinking about and that's maybe the coolest part of this study maybe the coolest part of this intervention is no performance didn't suffer the most important one you know we had our internal metrics and and certainly I think we saw decreases and failure rates in courses but the the marker that everybody cared about then was step one performance right that was the big test at the end of the first two years and what we saw is over this period of time the mean score Rose kind of paralleling an increase that was going on at that time but I think the thing that interests me most is the failure a dropped in half and it was less than half of the national average in a group of students who shouldn't have been been performing that well you know we weren't Harvard or Penn or Stanford you know Etc um we didn't admit you know a student body with a median MCAT score of 98 you know we had students who were high risk for failing and we were outperforming that those expectations and maybe at the end we can talk about I think that's surprising for some people that you can actually back off and improve performance but it actually makes sense partly because we over te partly because depression and anxiety are not helpful for learning nor is sleep deprivation so we created conditions where students could spend less time studying and learning and actually perform better so those were the outcomes and what I want to turn to just briefly then as I said I was doing this work before I kind of was aware of or had kind of created this amalgam model and I just want to return to that model and say you know how much did we hit those things so workload clearly right we we decrease the workload of students not just in class time or um the amount of time studying um students were studying more to chase scores you know now they could make choices no I've learned what I want to learn I've learned enough I don't have to chase more information because I want to answer it you know get a better score on the exam it didn't matter um second was rewards and this is a trickier one you know I I think this was more intrinsic that people had more opportunities to feel good about themselves um to to that their performance in in school wasn't just measured by scores on multiple choice exams it was how much were you engaged with with other people in in research or service you know tutoring mentoring Etc Community Connection is obvious I mean um we saw students uh relationships with each other strengthen there was no reason to compete cheating disappeared cheating was a problem and it wasn't people trying to avoid failing it was people trying to get honors instead of near honors connection with faculty improved as well because there was no arguments about oh you know uh that that you know that one question on that multiple choice exam you know I think the answer was c not D those disappeared um because people used to be chasing scores and grades autonomy was inherent in this we gave students significant amounts of time to decide what they wanted to engage in so so vitally important fairness um I think was an important one in in in a kind of an oblique way which is the grading system felt in you know at times inherently um unfair you know obviously you have to cut off for honors and to have you know one student who gets a 90 get honors and the one at 89 gets a high pass you know or half a point away from honors or the same for high pass versus past just felt unfair felt arbitrary values you know one of our values our mission statement was education of the whole person Mind Body spirit and heart um in the old curriculum I don't think we could say that we we really were doing that and so I think we created a place that was consistent with its values Mastery student had the opportunity not to just um uh perform well in in classes they also had the opportunity excel in spheres outside of the classroom which I think was important and this last one I think vitally important is again in those engagement in their extracurricular activities leadership positions service to others there was a sense of purpose and meaning that that had been really muted previously so it's kind of nice as I was you know thinking about this model to say yeah you know it really hit all the notes I think in a lot of ways and ultimately we created a new culture we created an entirely different environment um that that was you know filled with trust and and and warmth and and I don't know a a a a connection between Administration and and students that was profound so last I'm going to talk about in this last segment and I'm going to try and leave enough um time for for a little discussion and questions though I think I'm moving a little bit more slowly today sometimes I I I um drift in terms of examples but I'll try to move through this next segment quickly enough so culture I think one of the things in the well-being movement right now is there's a little bit of a tendency sometimes for people um to look at um leaders and say you're responsible for my well-being you're responsible for my S atisfaction don't look at me I'm not the source of the problem um it's up to you to create conditions that that that will in which I can Thrive and I understand that I think it makes sense in a lot of ways but as an absolute I think it's a really dangerous place we need to relay understand that we are all co-creators of the culture I don't care where you are in that hierarchy um you can have an influence either positive or negative on culture and so being mind ful about that is important one of the threats then currently um to culture within institutions that I see across the country is what I have described as kind of problematic but also really understandable mindsets that are are easy to develop in response to an an environment which is clearly clearly troubled um and no judgment you know uh for people who have these things I think again they're very understandable um so when I was traveling around the country before the pandemic I this was not you know this wasn't all pandemic that suddenly things went sour I was seeing really pretty much everywhere a sense of negativity cynicism pessimism frustration particularly on the part of residents and faculty maybe less so for for medical students but these were really profound and then since I picked up my travel um since the pandemic has kind of wound down is I'm I'm seing a change which I'm seeing even like a heightening of just outright anger and resentment that that feels different than what existed in before the pandemic and again given the troubles and challenges in healthc care and the inequities that may occur and the mistreatment and microaggressions etc etc understandable to feel this way but the question I have for people is is like do you want to live like this I don't think anybody wants to live in this space so I think we're challenged not to eliminate these feelings it's fine to feel these but to not kind of dominate our Persona and dominate our experience and I turned to a quote from Victor Frankle the the psychiatrist neurologist um writer philosopher and notably uh H um concentration camp uh surv ior um author of the book man search for meaning um a quote he said which I think is an important one is everything can be taken from a man but one thing the last of the human freedoms to choose one's attitude in any given set of circumstances to choose one's own way and so in these difficult times while it shouldn't be seen as accepting or condoning the conditions I think that that all of us are challenged to say what are the attitudes we're going to have in this in these circumstances how can we be a force for light in the midst of the darkness I think that's a challenge that that all of us face um not just in in healthc care but in life today as we face so many challenges so I'm going to end then with some individual tools that I think can help with these mindsets and potentially improve culture and again by offering these I I don't intend to be prescriptive oh you should do this this this Etc but I think what each individual can do is say are there tools that that you can engage in that that will help you be a more positive force that will allow you to engage with others in a way that makes them feel better and also you know ultimately help you feel better as well and again it isn't about being content with when there are inequities or or changes that are needed but as we work in those changes are those things that we can do um ourselves to help create a more positive environment um in the like clinical learning environment so a handful of these I'm going to run through pretty quickly so one is combating negativity bias so negativity biases we are all hardwired to have this which is that negative events will have a a more of an impact and a longer lasting impact than positive ones and it's the experience of going home at the end of the day you could have had a great great day things going really well and then you had just one negative interaction maybe a difficult conversation with a family or somebody who criticized you or was nasty to you a mistake you made a lab you forgot to check as any number one thing of those things and what the tendency is when you go home at the end of the day what are you thinking about it's often that negative thing and so you know what can you do about that one just awareness that we are all susceptible to this every one of us is susceptible to this and then one strategy is okay not to feel good about the negative thing but but how about running through all the positive things that that I did or happened to me today and and to try to put it into perspective if that doesn't work when you get home try to get engaged with something that's a distraction because more space you have from that negative event um the the the the softer it's going to feel the weaker it's going to feel so you know be being aware of negativity bias I think is is something that can be really helpful second is promoting optimism this is something that's kind of fascinated me in recent years is this it's something called explanatory style um and it's and and it's kind of optimism versus pessimism how do you view yourself and kind of your place and interaction with the world and and it used to be thought that this was like a character trait and it was fixed and we even talk about it in that way oh that that she's such an optimist or oh that person he's such a pessimist and and um it's not true it's not fixed it it it can change and if you want if you're a somewhat pessimistic person you can actually work to become more optimistic but what worries me right now is the opposite is true is that culture environment can pull you in a direction as well so if you're an optimistic person working in a pessimistic environment you will be pulled into pessimism it is almost impossible to avoid so the question is what can we do about this and I think a really important inter vention that I would encourage you to engage in is to really think about what are the natures of conversations you get to you have when you get together with peers or you talk to your family about how work was um I think there's a tendency especially with residents but I think this happens with faculty too is when you get a group of residents together and a by a group I say two or more you know where does the conversation usually goes and it often goes to like oh I had the worst call night ah this family's going to drive me crazy this nurse is impossible etc etc right and that's fine you need to vent don't eliminate that but if those are the only stories we're telling each other what kind of culture are we creating what kind of atmosphere are we creating and so I think this idea of appreciative inquiry where you don't just talk about the negative stuff but you also focus in on like what's good and because it's all there it's all around you every day you know being in the healthcare setting there are incredible stories of grace and beauty and selfe and courage and humor so tell those stories too go ahead and vent don't stop that but try to add in those those stories because those are things that can can I think fulfill you and make you feel better cultivating positive emotions this is a tool that I haven't used because it's just one where I'm a pretty positive person but if you're struggling with that a tool that's pretty well described and evidence-based as three good things which is if you have a just Journal at the side of your bed just whenever you can remember even on really bad days write three good things that happen and for clinicians it may be big things like you made a difficult diagnosis or or you had a tough conversation with family that you went thought went really well or you accomplished some Pro procedure or or it can be something small it should be something small and the example I always use um just because it makes me smile is is that like it could be like the burrito at lunch I had I had at lunch was just spectacular so notice those little things because they're around you every day um managing emotions I think I'm going to skip over because it takes a little more time if you want to if we can talk about at the end if in the question and answer period but I just realized I I um when I was at UCLA I was completely burned out and and what I realized is that that the way I put it is work got my better self so I needed to develop an ability to manage my emotions in more positive way especially for for my family my spouse and my kids um and again it just takes a little longer so I think I'm going to skip that one for now generosity and gratitude there are all sorts of approaches and I I some people make it a ritual and a kind of a practice to me that's not what I tend to do and I'm not dismissing it as an approach you got to figure out what works for you but for me it's just I think it's about trying to have an orientation towards that not just being part of your you know orientation engagement with others is take Delight in others be generous with others Express gratitude thank people for for for things um and my sense is the more you do that the more it comes back to you so think about ways that you can make that part of your daily life um managing ones self critical voice I have a whole talk on that you know the things like Mal adep or perfectionism performance as identity there are some simple tools that people can use and I'll just point you to um ACGME website called learn at ACGME there's a video Workshop that goes through these and then also series of podcasts if you go to any podcast platform and search ACGME aware there's a series of podcasts about teaching basically how to identify these mindsets but then also then tools to to allow you to kind of think differently to be exam to be able to examine your thoughts and to recognize when they're inaccurate and how you can create a more accurate and and um kind of uh personally supportive narrative about your own life and your own performance and then the last one is finding meaning and this is the one that that I'll end with which is um I just think so profoundly important and I'll return to Victor Franklin as I said the the Holocaust um concentration camp Survivor so many quotes I could use but I'm I'm going to end um end with this one and and he said the following there's nothing in the world I venture to say that would so effectively help one to survive even the worst conditions as the knowledge that there's a meaning in one's life there's much wisdom in the words of nche he who has a why to live for can bear almost any how so unlike the concentration camps unlike in Nazi Germany we have an opportunity and I'd say a moral obligation to change the how but as we work to change the how I I think it's incumbent upon all of us to kind of to kind of discover that why if you've lost it to find that why to feel that way why and ultimately be sustained by that and if we get to that place I think we're well on our direction to kind of a achieving a better state of well-being and health care and medicine so with that I will close um thank you all for listening I will stop sharing so that I can see folks and go to a view um and um yeah and open it up to questions so it looks like we have like six minutes to go so we'd love to hear from folks I see David has raised his hand David good to see you and good to see you steuart how are you good good pleasure I know you don't I know you don't like this word but I'm going to say it anyway I think you have done a masterful job of addressing this very complicated topic so thank you so much for your Pres presentation I appreciate it my question really has to do with measurement um you indicated that when you were at uh the medical school there you did some measurement trying to determine what the state of anxiety depression Etc was amongst the students there have you encountered any resistance to the idea of measuring that in other words occasionally you'll hear somebody say well gosh if we if we measure it and then we find that there's a problem then that obligates us to to do something about it so it's kind of a a head iny sand approach and then the other thing I know that you're aware of is there have been some very strong attempts to legislate some aspects of this so you know states to mandate some type of measurement what are your thoughts about that yeah really important topic or question and and a tricky one um we met no resistance on from our students and measurements and and there were a couple reasons why it's interesting our approach I'll try to be quick on this but but one is with our IRB this was all IRB approved second it was always Anonymous until we gave them the opportunity to make it confidential so it was Anonymous we actually got approval from our IRB to require it of our students which was interesting because we said these mental health outcomes we think are as important as board scores graduation rates Etc and and so well we and and we did it in class we didn't send it out so we had dedicated class time in my classes uh to where students would fill it out and we were able to kind of say why we cared and to make sure they knew it was in right so so those were features where we didn't get push back um from the students at all and they knew we were using it to improve the curriculum right this wasn't just a research project this was the primary focus is how can we do better so that was one feature yeah it I find it really interesting I think there's huge reluctance to measure depression and anxiety in medical schools still I uh and I don't know I find it Troublesome too that unlike residency we have no idea how many uh students are are dying by Suicide from what I understand there is no reporting requirement by medical schools when there are deaths of students which is not true ACGME asks every Residency program to account at the end of the year what happened with those students so I think there is discomfort um and and I wish it would change you know because I think only if if a sense of what the problem is can you really start making um uh interventions so tough issue David but i' I'd love to see people really move in that direction so thank you for that thank you excellent thank you what other questions or comments do you all have for Dr Slavin while we have him here it's a wonderful resource yeah my name is Amanda markuson I'm a actually a Residency program director I I was just wondering if you have any data I'm guessing you don't but do you know if what you did in the medical school was somewhat sustainable through residency I I feel like the residents come in on a pretty positive um note and it takes about five to nine months before I suspect over 50% of them are clinically depressed yeah um so just wondering if what you do early on has even if we don't change any anything in residency which obviously there needs to be changes is that somewhat sustainable yeah no great question and and I I wish we had longitudinal studies the only thing I can say which is completely an anecdote is I get to travel all over the country and give talks and and there's St Louis U grads all over the country and almost always students came up to me come up to me and said oh my God like you you made such a difference St Louis you made such a difference that I carry it forward and so I think you can though it's not enough right I it's I we need to continue to to strengthen that environment the other thing that I would say that's really important um and is part of the work ACGME gave me 15% time to work on Adolescent and young adult mental health um medical students are not escaping this this Mental Health crisis of our young and I think there's this idea that medical students start medical school with mental health better than or equal to their peers and it's just us that's doing this to them no they're they have profound vulnerabilities and I don't blame them it's not their fault and the research I'm doing actually is interesting isn't showing that social media is the problem in many communities it's School demands and academic pressure that's causing their distress these kids are are working ridiculous hours and homework and studying and extracurricular activities so they're coming in often with these mindsets of madep to perfectionism impostor and while residents looking at sent Sen's studies about 4% 5% maybe 6% will screen positive for depression at orientation we need to remember those depression scales ask how have you felt the last two weeks how do you think they felt they graduated from med school they're starting residency if you ask that same cohort of students or residents orientation whether you've had a history of depression 54% have had a history of depression so there is vulnerability that students that residents face that we can't blame them I it's not that they're weak they're products of their system it's not Psychopathology character weakness something they did but the education system before residency is causing them distress and then they're coming to residency again with maladaptive perfectionist um where they you know it's easy to feel like I'm not smart enough I'm not good enough and and really struggle in addition to all of the things like duty hours Etc and the challenges of medical practice so there's big stuff there that I mean we could spend an hour just unpacking I probably went too long on that answer but it's a huge issue Angela really huge so thank you for bringing that up wonderful thank you so much Dr Slavin this is been wonderful even better than yesterday yeah I think so wasn't it I think the second I think yesterday was great too I do think one of the most important points that you made is that we are all co-creators in this and I see that I see you see our audience we had the dean here yesterday multiple members from our Dean Suite program directors clerkship directors but we also have faculty at all points on the Continuum here and ready to make a difference so I think that says a lot for us and what we're doing to enhance the well-being of ourselves and our Learners so thank you so much for being here and encouraging us to do so with some practical tips on um how we might uh take some next steps so thank you all I hope you all have a wonderful day think of something really good I love that encouraging positivity when you hear grumblings even if you're feeling them inside yourself maybe um point out something really good about a recent encounter what like wow that that diagnostic catch you made earlier today was outstanding something along those lines I think are little things we can do to encourage that positive thinking um that's a little step in the right direction absolutely Shari just thank you to you and your team it's been a pleasure working with you all and again thank you for attending today um really appreciate you spending time with me so yeah take care all and and good luck with your work we'll see you thank you so much yeah sure bye bye see you all.