Wellbeing and Mindfulness for the Health Professions Educator

Good morning good morning oh it's so good to see you all it's good to see people in person also really does a lot for my own well-being so by virtue of your attendance and participation today here in this event um we definitely recognize that well-being and mindfulness is uh you recognize the importance of it and so hopefully that will grow throughout today's session uh we did have one session last night which was fabulous so you're in for a treat today um we are very grateful to have an expert in uh well-being and mindfulness for the Health Professions educator here with us today Dr Carter labares Dr liberas is an associate professor of surgery at UCSF and director of the UCSF Center for mindfulness and surgery she's a clinically active minimally invasive and acute care surgeon she received her medical degree from the University of Minnesota completed her surgical residency at UCSF and did Fellowship training at The ercad Institute straws bat Strasbourg University in France her academic research focuses on stress and performance in surgeons factors that influence health care provider well-being and the development of evidence-based policy and interventions to promote thriving in medicine she created the mindfulness-based intervention called enhanced stress resilience training esrt is an associate member of the American College of Surgeons Academy of Master Surgeon Educators and the community on Surge and well-being so please join me in welcoming Dr Carter levere thank you very much for this honor um it is really great to speak here and as I mentioned last night having yesterday to talk to people and learn about this school and this campus I'm actually tremendously impressed by how many systems and resources you have in place for wellness um as things stand so Bravo to you I see a lot of different institutions across the country and I talk about these things with a lot of people and you are really um in the Forefront in terms of how you're approaching this so Bravo um so today oh not working so today I'm going to talk about um a little bit about individuals and the universal stress response and how that really relates to resilience um oh thanks make a distinction between physician well-being as an individual State versus workplace Wellness which is a more complex environment and situation talk a bit about the evidence-based intervention that I developed and the evidence that we have supporting its benefits and then some emerging evidence about how individual focused interventions actually can have an impact on systems and culture and that's stuff that's just coming to the light recently um so this is a building in San Francisco and um I noticed it one day when I was driving past when I during my residency and it really struck me I found myself purposefully driving past it um more and more from there forward even when I was a young attending because I found it really useful to remind myself what am I grateful for as hard as this job is as difficult as some days are I'm still grateful for being able to be a physician to work with patients the honor of the work we do and that's often um the only thing I really had to hang on to um yet um I guess that's not surprising when I think about sort of the the life and the um rigor that surgery residents Undertake and I think it's important to set this framework before describing the intervention we came up with because it gives you a sense of how little time surgery residents have um to choose what they want to do electively so for the average surgery resident they're up at 4 30 um they're in the or by 7 30 and if they're lucky they're home by 8 30 pm and that means if they can learn to live like this day and day and year after year with only five hours of sleep that leaves four hours left in the day to do what they want so that's includes eating showering studying practicing their technical skills exercising socializing and they do this for five clinical years with two days off and every 14 and four weeks off per year and so you can imagine this is stressful um but this kind of stress actually prepares us in a way for this kind of stress so this is an exploratory laparotomy a big gut operation um this is a patient of mine who sadly passed away but for people who aren't familiar with the guts um the Pearly pink part on the left is the only part of these vowels that is healthy and everything else is either frankly dead or going to be and so this is another kind of stress and you might ask yourself you know some stressors can be modified and other stressors are inherent so there is a certain amount of stress that we encounter as healthcare providers that we cannot change no matter what we do and that's really kind of the life and death nature of our work and so when I'm talking about Wellness I'm not talking about creating a situation that's stress-free or trying to develop an environment where no one is ever stressed instead what I'm talking about is helping to empower people with an environment and individual skills that allow them to adapt to stress and Thrive despite adversity and this is the very definition of resilience and what this speaks to at its heart is that not all stress is the same so as this jerks Dodson inverted U-shaped curve expresses there's a relationship between performance and stress and on the left side of that curve with a certain amount of stress people are challenged they are pushed to adapt and find Mastery over new things and at the optimal point of this curve people's performance is at its peak they've found how to ride that wave of being activated without being overwhelmed and then on the far side there's Decades of evidence showing that overwhelming stress actually becomes toxic and is a threat to people functioning at their best and what often determines whether a person is experiencing life on the challenge side or the threat side of this curve is the relationship between their resources and their demands so that curve that process is something that people can learn to move along and it really is this relationship between resources and demands that we can work with in order to help people recognize they can't control the ocean but learn how to ride the waves and so it's by intervening in these two ways providing more resources or helping to mitigate demands that can give people some Mastery over the stress that just comes with life but it's also important to take from that curve that not all stress is bad and so that again the goal should not be to make our lives stress-free but rather to make the stressors that we undertake things that are challenging provocative and in a way um help us evolve so in the words of FDR column Seas never made a good sailor so my interest in this really focuses on the stress response itself and that's really for two reasons one is that some data I'll show you later but also Decades of data that's already out there in the public realm demonstrates that the experience of stress the perceived stress that a person experiences on a day-to-day basis has an incredibly direct impact on how one lives life both psychologically and physiologically so stress is really kind of a critical node in this whole process but I also love this territory because the stress response is a very Central and Universal experience and therefore if we're looking to develop interventions we're not trying to Simply address child care which is important or parking which really matters or a physician's Lounge which can make your day much better but each of those is a different stressor and considering that resources are limited we may have to rank the importance of addressing those things but stress itself is universal to all of us and so one example I always give is whether you're about to go on a first date or you see someone scary in the shadows when you're walking by yourself at night you respond the same way your hands get shaky your mouth gets dry your vision might become more acute your heart races but you don't do the same thing so in one instance you might run towards the thing that's making you stressed and in the other instance hopefully you will run in the complete opposite direction so something happens in this process where your mind notices a situation that causes it to become activated or stressed your body responds with the um kind of physical symptoms I described but then your mind takes in more information and you make a decision to run to or away from whatever it is that you're looking at and the importance of recognizing this process is understanding that as a process we can intervene along this timeline at multiple places and this is incredibly empowering so before going into the actual intervention um I just again want to underscore that there's a difference between feeling good versus being well and one of the reasons why I've spent years and a lot of resources um developing an Evidence base around interventions is because we need to really be focusing on tools resources interventions on any level individual systems or culture that are evidence-based and that's difficult you know burnout and people's distress it hurts us we feel desperate to change it but we have to have some caution about hurtling forward into an answer that might just be driven by our own personal experience that's a great first pass at how to address these things but I think we know in medicine that bringing science to Bear evidence to bear on a problem is really the most lasting and powerful way to come up with a solution and so I think this is important to discern because often we want to give people a happy hour or a couple hours off or some free sandwiches and that makes people feel good but that doesn't provide them with resources internal or external that allow them to weather the storm ride the waves on the ocean those are two very different things so in other words feeling good is personal and often situational going for a run having a glass of wine but well-being has established criteria it's a constitutional state it's persistent and it has flexibility across different scenarios and so um the definition I like the most for this concept comes from the U.S Centers for Disease Control and they Define well-being as more than physical health and housing well-being refers to the quality of a person's relationships their positive emotions sense of resilience realization of their potential and overall satisfaction with life and as we've been moving forward and thinking about physician well-being and workplace Wellness in these terms we're beginning to gather data that demonstrates that there is both an economic and a patient safety case to support these Pursuits and in support of how important these things are I think one of the best conceptualizations of how complex this workplace Wellness concept is comes from the National Academy of Medicine in 2017 they convened this collaborative action collaborative on clinician well-being and resilience and from this extensive period of time where they discussed and pulled evidence and and thought carefully about this issue they came up with this diagram which makes it very clear that culture and environment which is on the left in those concentric circles has a very um distinct role but also a very integral and inextricable relationship with work system factors and then individual mediating factors and so what's important about this to note is that no one part of this is responsible for the problem or the solution all parts are responsible for both things so while it won't be enough to just just address one element of this we do need to address all elements um and so my work focuses on the individual mediating factors and focuses on trying to provide additional resources internal resources to individuals but only as one part of this larger system so the theoretical Frameworks that my work is founded on are two the one that has to do with individuals and kind of internal resources is called the broaden and build Theory it comes out of resilience science and it talks about how the development and the purposeful maintenance of positive emotions like gratitude is something that individuals can do and while sometimes it sounds hokey like wearing pink tinted glasses if you think about the Mind as a muscle recruiting our thoughts back towards positive emotions is really like doing brain push-ups and we all know that we can walk down the same street and if we're in a lousy mood all we see is the trash but when we're in a good mood we see the people walking by smiling at us and we hear the birds in the trees so what one focuses on really does make a difference and in this Theory which is actually has quite a bit of empiric evidence supporting it now that state of cultivating positive emotions expands the repertoire of thoughts and actions available to an individual and so it inspires creativity and we know from neuroimaging studies that the part of the brain that actually is engaged in Creative problem solving is activated when people are cultivating positive emotions and in that state people are more likely to develop physical mental and social resources um so we all know what it's like to be around someone who's got a great attitude and um is collaborative we want to work with them and so people generate this of what's called an upward spiral of positive emotions um feeling good having more ideas and more collaborative approach recruiting more people who want to work with them and then having more success in the outside world and then that in turn generates more positive emotions so it's this really um positive upward cycle the second theoretical framework is job demand resource Theory and this really speaks to the fact that as positions our learning space and often most of our Lives is spent at work and so it's important to also look at um a theoretical framework that takes into account workplace factors this particular Theory focuses primarily on demand control and support and again much empiric evidence has been gathered showing that jobs can be highly demanding but if you give workers more control they maintain their work satisfaction up to a certain point at where this black curve levels off there's kind of a threshold where increasing demands have no returns but what we do know is that if the workplace includes support that curve is potentiated and people can do more with control but also with support and still feel happy about where they work and what they do so this gives us some sense of how we might think about the individual in the context of the workplace and so as the title of my talk reveals I'm interested in mindfulness and I didn't just pull this out of thin air um there's a huge body of research that demonstrates the benefit of mindfulness across high performance Fields but I was interested in surgeons and so this comes from a national survey that we did in 2016 across multiple surgical residencies and just asked about all the usual bad stuff that we were focusing on then so stress anxiety depression suicidal ideation burnout and then just on a whim I asked about mindfulness and this isn't mindfulness like I've been trained to be a yogi but it's a measure that looks at mindful attributes so kind of a way of looking at and interacting with life that reflects um the cognitive skills that underlie mindfulness and what we found was in those people who had higher inherent mindfulness the odds of all these other kind of horrible things things were greatly decreased and even more so than we had seen with any other interventions that were out there at the time and so this suggested that if possibly we could purposefully increase people's mindfulness we might be able to have an effect on these other outcomes and so again it's worth defining terms here by mindfulness training I mean a cognitive process where you learn to bring your attention to experiences that are occurring in the present moment and learning to observe those experiences without reacting and so very specifically this isn't a yoga class or a spa date or a foot rub this is a way of training the mind to sustain focus and to open its awareness so training in a different way of perceiving and a different way of responding to life and this is specifically taught through the practice of mindfulness meditation so diagrammatically this looks like people going along in their lives an event happens and this goes back to sort of the brain Body Connection I described earlier and then there's this space in between the event and our response and often how we decide to respond can result in either a seamless resolution or unending torture and this spot right here between the event and the response is really where the power of mindfulness rests and so in the words of Victor Frankel between stimulus and response there's a space and in that space is our power to choose and that response lies our growth and our freedom and so in mindfulness-based interventions and in particular the one that we've developed we are really asking people to practice very specific meditation towards these very specific cognitive skills which I'll explain in a minute and to do that practice of focusing attention and not reacting over and over again to strengthen this brain muscle and in so doing our hope is that we are giving people this internal skill set to ride the top of that curve to really move from Simply challenge towards Peak Performance mentally physically technically um but without falling off the cliff and in fact this has been shown to work phenomenally well in an incredibly diverse group of individuals um this is in use in the UK Parliament um and has been shown to increase collaboration across their version of the aisle it's been used in multiple ultra high performance athletes olympiads as well as kind of Legends in their own professional athletic world it's been used in the Marines and the Army to help with PTSD as well as the stress of both deployment and re-entry and it's been used in urban school kids showing improvements in pro-sociality as well as math scores and so our specific intervent specific intervention is called enhanced stress resilience training or esrt um we launched our first randomized controlled trial using esrt in 2016 and then using human-centered design over multiple years thereafter we refined this intervention really to make it feasible and acceptable so we all know in medicine now that this idea of bench to bedside actually has an incredibly long black box between the bench and the bedside and that black box really contains things that allow us to implement something economically feasibly that's acceptable and so over years we worked on that process but what we were aiming to teach our participants is three fundamental cognitive skills and these are shared across mindfulness-based interventions um it's something that the most effective mbis have in common and the first of those is attention and so this is both as I mentioned the ability to sustain Focus but it's also the ability to direct attention for instance towards positive thinking instead of negative the second thing is referred to as emotional regulation sometimes this is called emotional intelligence and it's the ability to both notice one's emotions as they arise but then also to be able to respond to them rather than just react and then the third is metacognition and you can imagine this is sort of our awareness of ourselves floating above and looking down on us and this is really the ability to see beyond just our own personal circumstances but all and to reframe a situation perhaps away from personal insult and towards a more balanced perspective but it also speaks to this idea of being able to recognize that we have these other two skills and so it's a way of sort of understanding the superpower we possess so we first went about demonstrating feasibility and acceptability um this is published in drama surgery I think in 2018. and the upshot of what we showed was that indeed even with that schedule for surgery residents that I described the participants in our study were able to practice the intervention group as the orange line they were able to practice five out of seven days a week and this was over at that time it was an eight week period and they were able to practice a mean of about 15 minutes a day that doesn't sound so impressive but when you think about that small four-hour period where basically all of life has to be taken care of before they pass out 15 minutes is a lot and most importantly it was sustained we were also able to demonstrate again the orange line is the intervention group um statistically significant increases in mindfulness and in Global Executive function which is a measure we used a measure established by the NIH which is like a executive function toolbox and what's interesting is these various time points number one is the pre-testing number two is right after the intervention and then on this scale number three is 12 months later and so you can see that some of these benefits actually evolve over time which is interesting um we also showed improvements to burnout both on the level of emotional exhaustion and depersonalization again with this kind of interesting relationship um between the controls and the interventions in terms of a greater development over time and we saw changes in neural substrates so this is uh image of the preferential activation that we saw in the intervention group only after the intervention and where we saw this happening was in the dorsolateral prefrontal cortex which is also known as the executive control Hub of the brain this is the seat of where emotional regulation is believed to take place and then the precunious or the posterior cingulate this is not as well of a understood area in the brain but it's believed to be the seat of self-awareness and mental imagery and then finally we also looked at physiologic markers of stress and we showed that the pro-inflammatory and fight or flight gene expression signaling Pathways were down regulated in the intervention group as compared to controls so to date now after this iterative process of tailoring and honing the intervention we have this internal curriculum we're calling it of five weekly one-hour classes where there's graded daily practice booster sessions we have a formal instructor manual and then this long column here is just one week of the very deliberate conceptual framework that we map these skills onto so we're not just putting people into a yoga class and hoping that they figure it out we're very deliberate about saying resilience is a learned skill the principle behind this is how you think about the world changes how you live in the world and then we go through video examples from other people we talk about exercises and developing a toolkit and so on and then we also have an app that helps with both the administration of the course and data collection and so I believe that this type of training this type of intervention fits into Health Professions education probably most closely by reflecting this experiential learning cycle of cold and so people get the concrete experience of being in class they have this reflective observation of watching others and doing things themselves there is a abstract conceptualization but we help them map that onto something concrete so they understand what we're training their brain in and why and then they get to go out into their daily world and practice these skills and so one way of practicing these skills is to actually sit on a cushion formally and cultivate less impatience frustration intolerance anxiety and be less reactive that's kind of the core training but then we also really emphasize informal ways that people can still strengthen their stores of mindfulness even though it's in an informal fashion so for instance like I mentioned just practicing gratitude focusing on things that are positive or that we love and this has actually been demonstrated to increase productivity and job satisfaction um also practicing transition meditation so that's not sitting on a cushion but doing things like when you walk into the elevator or Across the Threshold or you're going into the or one of the ones that we really emphasize is a transition meditation when you walk out of the hospital at the end of the day because it's so hard for all of us to leave work at work even when our bodies have exited the room um and this allows us to have Richard time off which Lord knows we all need and then finally um we can actively thought reflame reframe and I think this is particularly important when we think about the work on systems and culture that needs to happen because so many of us can become demoralized or really heavily biased towards the negative but if we're able to shift out of that we can access new approaches to Old problems um so this is a short video from a past participant in esrt this resident is about to go into her pediatric Fellowship pediatric surgery Fellowship training um at the time this video was taken it was three years after she had participated in esrt she participated in the very first wave and we invited her to make a short video really just to say it's not a complete waste of time but she surprised Us by describing the ongoing use of skills three years later I'm not sure how to make that happen that's what Heather's here for so I use the mindfulness for a couple of different uh techniques throughout the day I think one thing that's really helpful for me is mindful scrubbing in meaning before we scrub into surgery I like to take those two to three minutes to instead of thinking about all the things that are waiting for me and the surgery that's coming in and all everything else going on in life I just practice mindfulness and completely Focus myself so that when I go into the operating room I'm completely calm my heart rate's down and I feel like that way I'm a lot but I'm better centered going into the operating room I think it's also very useful to transition between work and home so before I used to go home and kind of bring all the energy and the negativity and stress from the day home with me whereas if I practice mindfulness as I'm walking or driving home I feel like that way I'm able to acknowledge the day kind of Let It Go and then go home without bringing it all home with me so honestly that was a shock um I kind of thought of these guys as you know guinea pigs that were performing and then would just run off and go feral again but apparently not so so use the mindfulness so that's good um so anyways that also gave us a sense that perhaps um there's more that happens than just the immediate um laboratory effects of this intervention which we had been focusing on so um now this brings me to covid um at the time of the covet onset we had begun to talk with collaborators around the country about trying to disseminate esrt and see if that was even possible if we could replicate it outside UCSF and how we might do that but of course everything got accelerated when covid landed and in particular one of my collaborator colleagues in New York um at New York Presbyterian Queens was watching the refrigerator trucks pull into the parking lot in the midst of all this death and horror and she called me and said I don't really care what shape this intervention is in we need something just help us and so we did not study it um really at the request of the people who needed this and I think that was the right decision um but what we did do was kind of fast track adapted it to a remote live streamed version and then um streamed classes across all four time zones over about an eight-month period on a repeated basis and in that period we provided this to a little less than 150 emergency room and surgeon Physicians as well as their providers our pardon me their partners because many of them were at home and so that was kind of a interesting added effect um the image just skipped over but the live streaming that we did um was a big screen just like this where we would send in um the live stream from one of our local instructors and then people in the audience had their mats and chairs and everything else they needed and were participating as a group um with the instructor being up on the screen so it wasn't ideal but interestingly it actually worked really well another thing that we noticed during the covid pandemic was everyone of course was assessing you know anxiety and depression and worried about how providers were doing and so we felt the same way at UCSF and we did some assessments of anxiety amongst our residents and what was interesting was that we found that um we had a great response rate to this survey 73 percent and initially when we looked at the data it showed us that anxiety levels were higher in the older residents and that didn't make sense because we know from years of research before covid that anxiety goes down and you can imagine you know people become more masterful and skilled comfortable with what they're doing so less anxiety but in fact we saw the opposite of that and so then we realized well we've only been providing esrt since 2016 and so maybe that has something to do with it all of these senior residents didn't have esrt because it wasn't available to them so we reanalyzed the data looking at who had been trained in esrt and who had not and when we looked at it in this fashion we found that those who had not been trained were six times more likely to have clinically relevant anxiety scores than those who had training and this was actually independent of pgy level gender age number of hours worked whether or not they had children or a partner at home who they were worried about infecting and um the level of exposure risk in the setting where they were working so developing the um online form was actually a tremendous Silver Lining to covid it has allowed us to really extend the reach of our collaboration with people um um upcoming we're offering classes in the Middle East both Kuwait and Lebanon um having collaborators that are both in medical schools like the learning communities Institute and then multiple surgery programs um in Europe and the UK and across the United States and one of the beautiful things about collaboration is that other people do work too and so there's been a bunch of research that has started to come out from other groups showing the impact of using mindfulness training on systems so things like or teamwork patient experience humanism and professionalism interpersonally between people working in the hospital Etc and then really hot off the press um stuff has been coming out about the impact of mindfulness training on culture and so this particular information comes from the second trial this is a massive trial that's being done in general surgery it includes 99 of all of the surgery residents in the country um and um greater than 250 acgme accredited programs for this particular data set which is qualitative it's comprised of 211 interviews that were done across 15 different institutions with interviews conducted with residents program directors Department leadership and then faculty and what they distilled from this was when they looked through a framework of emotional intelligence competencies they discovered that in some residents this arose in a kind of de novo fashion so they just maybe naturally had greater emotional intelligence and when they did they had a qualitatively different experience of residency they were um took things less personally they felt that the stressors were more challenges than something debilitating or overwhelming and then when they looked at programs that purposefully implemented group strategies like esrt or like a program that was developed at the University of Arizona they saw culture-wide changes so they found recurring mention across all these different levels of interviews of Greater psychological safety which fostered these growth mindsets of a more cohesive Community which was repeatedly described as being founded in a positive way on vulnerability and using a shared common language to um describe experience and then public opportunities for expanded learning so for instance M Ms that were not punitive but instead were very much group focused on finding Solutions and that residents felt that the presence of these programs um uh was a competitive advantage in terms of their selection of where they wanted to train similar kind of global benefits are also being seen at Swansea Bay University they're now in their third year of studying a longitudinal cohort of residents who received esrt they have a really amazing data capture system in the UK that collects Global Information about test scores technical performance professionalism it's all stored in one database and just this month they emailed me to say that they're now beginning to see a Divergence in these Global scores and that the residents who have taken esrt are beginning to show benefits in all three of these areas so the last thing I'll just mention is that um going back to the idea that it's not just about individuals or systems or culture we've begun to start to look at how these three things interact and so this is a social network analysis that was done on a data set that we got from several hundred general surgery residents across 19 programs and um the way this kind of analysis works is it creates sort of nodes of influence and so for instance the red node over there is mindful Tendencies it's a measure for mindful Tendencies and then the yellow nodes are elements of job demand resource Theory so support control and demand in the workplace and then um the bright green nodes are the elements of burnout so personal accomplishment emotional exhaustion or depression in the center the PS and ewb are elements of what's known as flourishing and this is a measure that we've been really pursuing um as this research grows because we're interested in understanding not just who doesn't have burnout or who does but really trying to reframe how we set the bar and so flourishing is actually a very well established measure in psychosocial research and has very strong ties to clinically relevant metrics so the utilization of clinical resources absenteeism at work as well as mental health outcomes and when people have high flourishing it's representative of having positive psychological social and emotional functioning and so what's kind of beautiful about this is it sort of captures an interaction with your insides your outsides and your attitude and so um we've done some other work that I'm not going to talk about um testing for validity evidence of this measure in surgical trainees and it looks like it's it is valid um and so now this is kind of the Leading Edge is beginning to understand okay mindfulness the red node has a a negative effect on that purple node which is stress it has a positive effect on this flourishing Triad but you can see those lines aren't that dark so it's a it's a real effect but it's not a very strong effect so well that's the best we've got right now there's a whole bunch of opportunities here to develop things that might be even better so for instance the relationship the influence between emotional exhaustion and depersonalization that's huge the relationship between the influence between anxiety and stress that's huge so this kind of opens up a sense of where we might start targeting the next phases of work um so this just describes some of the associations that um we know from the literature which drove us to select these particular measures we know that personal accomplishment is one of the strongest indicators of attrition from surgery um anxiety and suicidal ideation have a very strong relationship as well as the other things you see here um one of the things we did identify using this social network analysis to um evaluate for the direction of Pathways is that mindfulness does indeed um work through stress in order to have effects on things like depression or emotional exhaustion so anyways there's a lot of work out there still to do this is only one small area of a complex problem I like to end this talk by saying that really physician Wellness workplace Wellness is an innovation which means that it's radical and disruptive and makes a lot of people uncomfortable but is very much necessary also right now it seems like this huge complex and almost insurmountable problem but we have felt that way about things in the past and so I think we just have to look to history to remind ourselves we just need to stay the course the example I like to give especially because I've seen your absolutely gorgeous Simulation Center is that when I was a resident it was actually considered a sign of um Quality in a surgical training program to not have any simulation and so the joke was they'd show us a dark closet with a trainer box and say yeah there's our Sim lab you know because like that's all we need today there's not a single self-respecting surgery program that wouldn't have a gorgeous heavily resourced Sim lab I'm not sure any of them have I've seen are as beautiful as yours but it just shows you how staying the course pays off um so in summary mental skills training to mitigate stress has a strong body of evidence supporting it um it's important to remember physician well-being and workplace Wellness are very closely related but they're distinct and they require kind of different approaches and that workplace wellness and medicine is innovation so it really requires us to work together collectively to tackle this thing but I'm absolutely certain we can do it and thank you foreign all right so any questions here or online I know Mariah is monitoring the questions online if you have any comments concerns questions pop them in there and we will answer them um I will tell you for those of you who do have meetings scheduled with Dr labares today you're in for a treat she we had dinner with her last night she's fascinating there's so much more behind this presentation which was great to start with so um questions concerns it's kind of early we have one over here excellent then another thing for a terrific program this program was excellent and thank you for this uh terrific program thank you let me get you the microphone so they can hear you on first of all thank you so much for a wonderful presentation very powerful evidence-based comprehensive that's fantastic thanks um I wonder how many do you have any idea how many surgery programs have adopted this approach um so there's probably within the United States close to 15 who have run the program but it's quite different to run the program once and to adopt it longitudinally and so that's something that we're really working with programs on now um those that have really invested resources include UCSF which now offers this every year to our incoming interns and it's created this shared vocabulary so one of the stories I like to tell is that I was in the operating room doing this horribly stressful case and I warned the intern and the chief beforehand that it's not personal but it could get ugly in there and it did and in the midst of it I have the intern over here and the Chiefs over here and the chief leans around me and says this is where you use those techniques she taught you like to deal with me so anyway um there is this funny longitudinal like intergenerational thing that's going on um it's also been adopted at UCLA now for multiple years I'm at the University of Washington um and then the other schools that have really invested in it are in the UK and in Europe and fascinatingly uh you mentioned last night that vet schools are starting because yes I did not know because those charts that we look at um that talk about suicide rates really focus on Medical Specialties within human medicine and uh Dr lamarris mentioned that veterinarians have the site's highest suicide rates among the medical professionals and they have really adopted yeah so actually um UC Davis will roll out esrt across all house staff and then move it to faculty um in 2023. I really like what you also said early on in the presentation there's there's a distinct difference between feeling good and being well and I think a lot of times you can feel good individually and do things to feel good and then there's you know the being well encompasses so much more organization wide and really implementing uh a cohesive package all together to to really hope help everybody to be well including the patients yeah well it's part of what um different programs are coming up against so Emery Baylor New York Press um the University of Minnesota Iowa different programs that have implemented this on a on a single session or a few session basis are realizing um it only works if people have protected time so it isn't just that you're offering a course you have to arrange protected time for the resident attendees and then you have to share the evidence base before the course so that people understand it's not just another yoga class and then for instance at the University of Washington they realized that they had greater buy-in and in the end even saw better benefits if one of their own people was trained to be the instructor and so now there's a young faculty trauma surgeon who is just newly Minted as an esrt instructor and so there's a lot of the process around any intervention that has to be sorted out but we're figuring out how to help people do that okay any other question uh Dr Paul thank you so much um very thought-provoking um I'm wondering about sort of stretching the circles out and are you um looking at other Specialties and about faculty um training yeah so um at UCSF we've provided this to OB gyne which Incorporated it as part of their fundamental intern training what's interesting is that in surgery we had a big discussion about whether it should be mandatory or elective and currently we've landed on it being elective but in the back of my mind at least I think you know Anatomy is not elective and the surgical skills lab's not elective but we're still at a point where um focusing resources on strengthening our minds is a little strange and uncomfortable for people so I think it'll be a bit before we treat mental skills training the way we treat anatomy lab but in OB gyne there was no controversy at all they did it once and then their program director said oh this is how we train OB guides at UCSF and so then they just did it and no one balks or complains it's just part of it's like putting your pants on to going to work every day um so we've also extended it to Psychiatry Pediatrics and this is at institutions outside of UCSF Urology Family Medicine Internal Medicine gastroenterology at Tufts is starting a program um faculty is a different story we did provide it to UCSF faculty and it was very well received but faculty don't have protected time and so this goes back to the question of you know how do we establish sustainable uh interventions so not just trying to figure out the um golden bullet or the perfect pill but recognizing these are these have to be systemic and longitudinal interventions and that means a lot of other things have to change to accommodate them to me that speaks to how important it is to have evidence because if we're going to make that much change and invest that much resource we really do need to make sure we're doing it for things that work but the second thing is for faculty it raises this question of um if you have to choose between going home to have dinner with your children the one night a week you might see them before they go to bed or do something good for yourself most people are going to choose to spend time with their families totally understandable but that shouldn't have to be a choice so one of the things we're working at in the American College of Surgeons is to recognize that burnout overwhelming stress some of the other sequelae that can come from the work we do is in fact a workplace Hazard so when those things occur it is not because an individual isn't strong enough or cut out for this but rather because it's like a construction site you know dangerous things happen and so you wear a hard hat so the idea being maybe what we need to do is incorporate the opportunity to have training like this into the workday so maybe it has some rvu's associated with it or maybe it takes the place of some other piece of our work that we have to do we're still figuring those things out other the question that came in online was exactly your question no um is there are there any more questions online at this time right anything else going once just to let you all know online and in person um if you'd like to share this with your friends and colleagues we have another session being presented at noon today um it will be a hybrid session as well the in-person chess session will be over at the hospital in Med Ed classroom three and uh there there's a link on everybody's calendar for the zoom session so if you would like to attend Dr lorberis does Shake every session up a little bit so it will be a little bit different if you want some additional information but please feel free to join again or encourage others to join if they are able otherwise thank you and have a wonderful rest of the day be well.