Welcome everybody. Thank you so much for joining tonight. I'm going to pull up my PowerPoint here to share with everybody. There's a lot of webinars going on these days. I really appreciate everybody's time and joining us for this important topic. As we all know, burnout among physicians is a hot topic that's getting more and more attention for good reason. Very high prevalence and a lot of contributing factors. While deriving enjoyment and fulfillment from our careers has multiple contributors, including satisfaction with what we're doing, feeling as though we're excellent what we're doing, as well as making time for exercise and time for outside activities and time with family. Peer support is a huge part of physician wellness and so I really appreciate that we're dedicating more time to this topic and have webinars such as this one. The outline of the talk for tonight, we have an awesome panel of speakers. I have personal connections with all of them that I will share. We'll start with the case for peer support, why it's important, why we're here talking about it, and why we have programs for peer support. We'll talk about ethical dilemmas and adverse events, how peer support programs actually work, and using them at your institution that are available to you or even implementing one at your program or institution if one does not exist because they're very important. These are all of our speakers for tonight. Of course, myself first. I'm in private practice in the San Jose area with a focus on sports medicine and trauma within orthopedics. I'm the chair of the Ruth Jackson Orthopedic Society Professional Development Committee. Really appreciate this partnership among AOFAS and the Glotton Society to get these webinars together. And I'm on the Physician Wellbeing Committee at El Camino Hospital. Casey Humbert joins us from Johns Hopkins. She is really experienced with medical bioethics. I've listened to other podcasts and talks that she's given and they're really dynamic, interesting, with a lot of great information, so I appreciate her joining us tonight. Next is Dr. Raymond Shaheen, who I know from this area of practice. He's also in private practice. He chairs the Ethics Committee and the Physician Wellbeing Committees at El Camino Health. And Kiran Gupta is Assistant Clinical Professor of Medicine at UCSF, and she is the Medical Director of Patient Safety in the Caring for the Caregiver Program at UCSF, from which I've personally benefited. So peer support, it might not fulfill the Cobra Kai mentality of strike first, strike hard, no mercy, but it is part of an important part of defense against burnout, and it's quite powerful. So I think this series of talks tonight will convince you of that. And thank you so much again for your attention, appreciate you tuning in, and we'll get on with the other speakers tonight. First up is Casey Humbert. Good evening, everyone. All right, hopefully everyone's seeing my disclosures so I have no relevant disclosures for this particular talk, but I'd like to disclose the $12 a year I get from Oxford University Press. I'm also an AOFIS board member, and an AOS committee member. So, peer support. I always hesitate to ever use a definition from Wikipedia in a talk, but in this case it was the best definition that I found so I went ahead and used it. So, this is how Wikipedia defines peer support. It's when people provide knowledge, experience, emotional, social, or practical. I like how broad the degree of support is in this definition, that it's not purely emotional. It's really just practical support to each other. And it refers to initiatives where its colleagues, members of self help organizations and others meet in person or online as equals to give each other connection and support and a reciprocal basis. It's different than perhaps counseling which may have a clinician patient relationship. It's different than coaching which is hierarchical. The point of peer support is the meeting of equals. And this definition really emphasizes that the relationship is one of equality, and how this is a distinct relationship, because the individual has been there and done that. So there is a different level of trust amongst the peers, by definition. So when I was first asked to give this talk I was thinking, well, why do I really need peer support does it have to be a peer, does this make sense in a different framework. I have a phenomenal family I have wonderful friends, many of whom are outside of medicine, who have a diversity of experiences I'm incredibly close with my sister. And I started to try and think of why would I ever need peer support. So this is a personal story and this isn't the actual x rays of the patient this is just a different by malleable or ankle fracture that I encountered. But I was in my first couple months of orthopedic practice, and I don't think that anyone can ever really tell you until you're in it a little bit like parenthood, how miserable, starting out in your own practice is in terms of the self doubt the fear knowing the pressure is all on you when things don't go well. And I had had a by male ankle fracture, and similar to this one it was one of those long oblique fractures that has that proximal spike, which everybody can see on the far right. And I was fixing it. resident but at the end of the day I was the attending and that spike broke. And so you had that perfect reduction and then it was lost me to take it all apart. And we had to start again, and I called my husband on the walk from my operating room to my car at the end of the night where I was feeling completely demoralized I'd had this perfect reduction and then we broke the spike and did I put the clamp here and my better half response was, oh my god did you make it that somebody is never going to be able to walk again. Not a helpful peer support response. So I said I really can't talk to you right now, I sat in the car and cried. And then I called my dad, who in addition to being my dad is an orthopedic surgeon. And I told him what happened, and his response was, that's perfect. Even more bone for healing, which is exactly the right answer right that posterior spike doesn't matter at all the fracture was out to length he said show me your x rays he walked me through it. At that moment he was very much not a parent, he was a peer. That's why we need this, because other people who haven't been there and done that as the Wikipedia definition says they're not helpful, and these circumstances. So where else do we see a lot of peer support. So the most common area that I think many of us would think of when you think of peer support comes from substance abuse or alcoholics anonymous. And these have peer support relationships that are formal and structured because they've been shown to help with the success and recovery. So, your peer support is often called your sponsor, and they have to be someone who is in recovery and is successful in their recovery. But the idea is that in super difficult stressful hard things when we're trying to do hard things, such as be a surgeon, or be someone who is no longer using alcohol or drugs. You need someone else who's been there. And the more I thought about how this model and how it's successful the more I thought, I really think everyone should get an assigned peer support person, like a support animal at the beginning of training and you have to work with them the rest of your life. Just similar to how a sponsorship program and clearly different than a mentor mentee which is hierarchical. For surgeons I think it's incredibly important this is one paper from archives of surgery, almost 80% within a one year period of surgeons experienced and a serious adverse patient event or traumatic personal event. And when you look at who were they willing to go to for support. 88% felt that other physician colleagues were the people they wanted to go to. Only 30% want to go to employee assistance programs, and less than half are willing to go to mental health professionals. And to me that really holds true. I, when I was crying in the car I wanted to talk to another surgeon to reassure me, I wasn't going to call the employee helpline and say oh my gosh I'm having a meltdown because they wouldn't get it. And I responded like my better half of is that person ever going to walk again. Also, because we are evidence based folks peer support works. So this is one study from the Journal American College of Surgeons from June of this year, and it had a pretty high success rate when you're looking at programmatic evaluations 81% is a pretty darn And people were very satisfied with the amount of confidentiality and the fact that they felt it was a safe trusting environment. And the goal of this is try and prevent the second second victim effect which we know is a driver of burnout. Finally, because this is a joint event with Ruth Jackson I want to emphasize that I think that peer support is going to be of particular importance for women. We know that perfectionism as a culture is increasing over time so there are ways that you can test for perfectionist traits, we also know that women are more likely to be perfectionist. I think women are at particular risk in the field of orthopedic surgery. We're a minority. There's a lot of imposter complex which is amplified when one is a minority. There are dynamics ongoing, such as the second shift at home, where people are launching their careers is also a very stressful time often in one's personal life as you're running out of time to have babies if you want to do that. You don't are less established you have more financial stressors. This is why we often get burnout early in our careers. I've become a Brene Brown junkie during this pandemic it's what's getting me through. And I love this quote about what is perfectionism. And she says perfectionism is not the same thing as striving to be your best perfectionism is the belief that if we live perfect look perfect and act perfect, we can minimize or avoid the pain of blame judgment and shame. It's a shield. It's a 20 ton shield that we lug around thinking it will protect us when in fact it's the thing that's really preventing us from flight. I will freely admit that I still live far too much of my life, believing that if I have the perfect x ray. If I have the happiest patients and best reviews. And if I managed to get Pilates five days out of the week. Somehow I'm going to be protected from bad things happening. This is perfectionism is something I'm working on, but I will know that the moments that I'm most okay with feeling not perfect is when I'm talking with my peers and realizing that they're having the same struggle. I truly believe that, and this is a hypothesis I don't have great evidence for it, but that only peer support is powerful enough for us to come together and overcome this 20 ton shield of perfectionism. So hopefully I've convinced somebody that peer support is important and will work. And with that I'm going to hand it back to our moderator. Casey, thank you so much. I really so much of that resonated with me, especially really meeting somebody who's gone through it, done it, and giving you advice. Personally, I've found a colleague who's about 10 years ahead of me in practice to be just invaluable when I need five minutes to realize, hey, we all have cases that don't go perfectly. We all have patients that don't do perfectly that have complications and hearing it from somebody you trust and admire and who can tell you that they've been through it too and assure you that everything you did was reasonable and appropriate is just incredibly powerful. So with that, we'll move on to Dr. Shaheen. He's another person who he's the chair of the Physician Wellbeing Committee I joined and I remember when we chatted when I first joined, he said, you know, you're young, you're hustling, you're trying to grow your practice, keep lawsuits off your back. And I thought it was just so appropriate and I really appreciated that. So with that, we'll move on to Dr. Shaheen. Thank you, Jyothi. I'm glad to be a part of the panel today. I'm still seeing your picture. I do remember that conversation and I usually introduce when people say, are you in charge of the Ethics Committee? I say, yeah, that makes me ethical, right? You know, it's a, it's kind of a daily renewal. The topic that we're going to be talking a little bit about today and I'm going to get my slides to share with you is, as you have listed there, ethical dilemmas and adverse events. The, I think we all kind of have a idea about obviously what ethical dilemmas are but I'm going to spend a little bit more time in a moment. These are my disclosures. I don't have any disclosures for this specific talk. My way of an outline, I want to first go over some background and basic definitions. Obviously, then talk about some of the impact physician wellness and adverse effects have on us and our interactions with others. How to identify when we're in a dilemma, because sometimes we have blind spots and we may not be self aware about that. Of course, resolving these dilemmas and then some conclusionary statements. So, by way of a little background and definition. Frequently, people ask me, well, what's the difference between moral and ethical, right? It's certainly not the law. So, it's more of a gray area but generally we all know that moral generally is a sense of right or wrong. What's the right thing to do? What's the wrong thing to do? And that's probably the most basic definition but it may get into religious standards, your religious heritage, moral expectations, personal. You can think of it also many different ways, like a personal sense of your values or your ethics, personal ethics, I should say, your conscience. And because it may be so ingrained and meshed with your upbringing, it can be rigid and unchanging in many cases, but not all. And then, you know, ethical is more like a multi-person moral dilemma. It really takes into effect the societal and professional standards sometimes, the people around you, and so you may be in conflict with your morals and the ethics around you may be in conflict. And ethics, like any society that's progressive and change is constant, can change over time as well. So, I don't mean to have this being a thought experiment, but can something be ethical and immoral and can something be moral and unethical? And it's kind of double speak, but you could put some of these individual categories into both categories, answers into both categories. For example, physician-assisted dying. I have a family member who's a staunch Catholic and thinks that any step on your part to compassionately made someone comfortable at the end of life would be a sin. And so that's a moral rigidity that you just can't get beyond. So, it can be seen as an ethical, compassionate thing while others may see it as an immoral act. And it could be the other way around where that family member could think it's immoral and unethical. And so I don't think this is a perfect example, but I'm just trying to show you how in the eye of the beholder, certain actions and certain positions can be seen differently. And that's where these dilemmas can arise between internally on our own and when we interact with our colleagues at the hospital or in our personal lives. I just give another example there about converting someone to comfort care when they're a full code out of compassion and best medical judgment. And that may be a moral decision, but if you do it the wrong way, it could be seen as unethical if you don't have the appropriate checks and balances and stakeholders involved. So anyway, to belabor the point on that, let me move on to the next point, basically to say I see ethics as the ceiling and laws, the floor. If you think of it that way, I remember having a conversation with one of our hospital general counsels of looking at our call contract. And I wasn't talking about the contract, I was talking about how colleagues treat each other. I said, no offense. Usually when someone says no offense, you know they're about to make an offense. So I was like, no offense, but I see the law is the floor and this is the minimum standards that we are trying to abide by that just keep us playing well in the playground. But we should expect and hope to expect more than that with each other. And over on the far left of the slide where I show morality, sometimes morality may be beneath the law and it may be above ethics. And it just can range between all of the above because it's such a personal matter. Legalized marijuana, right? Is it immoral? Some people might think it's so. It's changed over time. The laws have changed. But this is a general construct to think that there may not be much of a gap between ethics and law, like slavery is illegal. That sounds like an ethical, moral law, but sometimes there's huge gaps between the two and you kind of need to know where you're standing on that. So back to the outline. Next thing is about how these things weigh on us and impact us in our wellness and in terms of adverse events. Well, ethical dilemmas cause moral injury, right? Meaning that we are not at our best selves that can cause compassion fatigue in us. So that may be manifested in many different ways. Reduced confidence, we kind of alluded to that as younger surgeons getting started in our practice. Even in a pathologic way can even develop into a self-loathing, a regretting about bad outcomes. Avoidance, maybe avoiding others and not being collaborative, maybe being embarrassed or ashamed to discuss these matters with your peers. And then you can be punchy and snippy and be impatient and irritable with your team and your staff and nurses and your family. And then things can really avalanche down to self-medicating and of course, tragic suicidal ideations and other things, obviously. So in that ilk, yeah, how does it affect our personal and professional relationships? I mean, first and foremost, I would say, this can put serious risk of harm to patients, right? Our judgment, our clinical management of patients can be jaded if you have compassion fatigue, you're gonna do an amputation, do an AKA and be done with it, and you might not even, it might be efficient, but is that the most effective way to resolve your dilemma? And it can impact, obviously with marital discordance or divorce, erratic behavior and violent outbursts and getting in trouble with the law and obviously can have tragic outcome death. I alluded to this earlier, how do you know when you're standing in the middle of an ethical dilemma? So if you see that, you're standing, that guy looks like he's standing in the middle of an ethical dilemma. Well, very simply, the most common one I think I see is when I get an ethics consult or I'm talking to a doctor or the young hospitalist and I'll cut to the chase and I'll say, do you know what the right thing to do is? And so if there's a gap between what you know to be right and what you were doing, obviously that's a dilemma and that's a challenge. And sometimes the physicians won't know, right? Neither option resolves the situation to a morally or ethically acceptable decision, right? So if you have the patient at a DNR and you're doing full throttle active care, providing surgery, feeding tubes, trachs, anything to them and you're conflicted about that because you know the risks of harm and you're asking what the heck am I doing and the patients should be made comfortable but you have some gap that's preventing you from converting them to comfort care and either one, comfort care, you may feel like you're actively contributing to the patient's death. So that may be a challenge that you may not be able to mitigate yourself or resolve yourself. So that leads right into how do you resolve some of these ethical dilemmas? Well, you gotta take action, obviously, right? Leadership requires action. Physicians are leaders. We're leaders in small ways and little ways and big ways. In the OR, on the floor, with the nurses, with our colleagues, you don't need organizational power to be a leader, right? You can just start doing the right thing and being who you are and setting an example and competing with an integrity standard. So you can do something. You don't have to feel like, oh, this chief medical officer, blah, blah, blah, the hospital, blah, blah, blah. You really need to take a step forward and obviously the first, even better, is prevention, right? Having all those journals piling up on your desk, maybe don't have them mailed to your office, right? Little simple things like that in a small logistic way. But more importantly, prevention, maybe not marring yourself down with a business relationship that you think is kind of shady, something you don't believe in. Someone's trying to hire you to be a medical director of X, Y, and Z. And you're like, thank you, no thank you. Preventing yourself from that problem and that conflict of interest is probably an ounce of prevention's worth a pound of cure, right? So all of the action steps require moral courage. You're going to have to get out of your comfort zone, take a risk, be comfortable being uncomfortable, and that's all the things we do in the OR or with patient care. We have a target on our back sometimes and sometimes we have to make those tough calls and decisions and get out of wherever. If we're in a dilemma, we have to step out of it. Sometimes we bolster our moral courage by committee, right? We get second opinions, historically referred to as loading the boat, but basically getting other trusted counsel from other colleagues medically to weigh in on your case or we're going to have other talks about peer support outside of a specific case, but getting a second opinion, working with other elements at the hospital, such care coordinators, palliative medicine consultations, ethics consultations, wellness engagement, and of course just making sure what you're doing is appropriate and legal, right? If you're converting someone to comfort care, are we doing it through the right proper channels? So in conclusion, some of the takeaway points at the end I wanted to mention were that ethical moral dilemmas limit our ability to provide the highest quality of care to our patients. They exact a tremendous toll on us personally and professionally. They can damage our relationships with family, friends, colleagues, and even the safety of our patients. And you really need to take swift, direct action to resolve these dilemmas when they arise to protect yourself and your wellbeing and all those around you that you engage with. And lastly, as I mentioned before, I'll finish with that. Prevention of ethical moral dilemmas is the most effective way to prevent against these challenges. So with that, I will toss this back to Jyothi. Thank you, Ray. That was great. I'll just share a quick anecdote on an orthopedic case that I had to involve the medical ethics committee or I guess more appropriately, the medical team had to involve the medical ethics committee but we had a patient come in while I was on call, homeless gentleman with untreated psychiatric diagnoses, which made him incapable of making decisions and had an intertrochanteric hip fracture, which bone broke me fix as an orthopedic surgeon. You can't bear weight on that. But of course, I worried about follow-up, the patient's homeless, is he gonna have any follow-up? Is he gonna infect a wound, et cetera? It ended up being about a month actually of exhausting all options, searching police records, trying to see if he had any family. So I really appreciated all that work that Dr. Shaheen put into that to make the decision the right way since the patient cannot make decisions. And of course it was a long drawn out process and then the day of surgery, the nurse in the pre-op area says, Dr. Morelli, he says he doesn't want surgery. I said, he's been saying he doesn't want surgery for a month. We've gone through all the appropriate avenues. And I know this. So things have to be done in a certain way and documentation needs to be done. So I appreciated the medical ethics getting involved and making what was ultimately a tough decision done in the appropriate manner. So with that shared, we'll move on to Dr. Kiran Gupta. Dr. Gupta, I connected with, I'm on associate faculty at UCSF and I had a particular case that was tough for me to deal with. And I saw that peer support was a resource and connected with her and she connected me further with peer support. I found it to be immensely valuable. So I will open the floor to Dr. Gupta. Thanks very much for having me. I really appreciate it. I'm just gonna share my screen. Okay, so I'm gonna talk to you all about some of the peer support work I've done at UCSF and specifically how peer support works and a little bit of the nuts and bolts I thought about when starting a program. My disclosures were already mentioned, but similar to others, I received some very minor royalties from McGraw-Hill regarding a textbook on patient safety that I helped author. So I'll talk a little bit about understanding the benefits of a clinician support network really briefly. And then I'll talk to you about our experience at UCSF. A little bit about why peer support is important, underscoring some of the points that have already been made and specifically really to highlight why it's important even when other resources exist. And then a little bit about how you might wanna start a program. So in terms of just the benefits of a clinician support network or a peer support network, I think broadly about these four points. It's a way for staff, providers, those caring for patients to get their needs met after something that's happened is traumatic on some level. It really does in the longterm, I think help reduce the harmful effects of stress. And we're seeing more data on that. Hopkins recently released a study showing that it actually helps reduce the intent of staff to turn over and leave an organization. It provides some normalization and helps individuals get back to their routine after a traumatic event. And it promotes the continuation of productive careers while building healthy stress management behaviors. And I think the other thing to remember when thinking about peer support is not everybody has the same needs. So it's really important when thinking about a program that it be broad enough to meet the needs of a lot of different types of providers and staff. And then I think awareness is also really, really important. There has to be a lot of proactive planning and education to people regarding what happens when there are adverse events and errors. And then just remembering that the fear of the unknown is really profound and increases people's stress and anxiety. And then I think it goes without saying, people who work in healthcare are perfectionists. That's already been mentioned. And we're used to being the people who help patients, who help others, who help our team members. And there's a real stigma to reaching out for help in healthcare, even though we would tell our patients not to hesitate at all. It's sort of like do as I say, not as I do. And then I think just thinking about the healthcare environment, high acuity areas have very little time to integrate what's happened. And then thinking about the OR and the turnover and going from one case to the next case or my ED colleagues where it's one patient after another. As I said before, there's a lot of fear of the unknown. And then I think people really feel, they put a lot of weight into what their colleagues think of them. I mean, people really wanna be respected. They wanna feel like they're a trusted member of the care team. And I think when something doesn't go well, there's that feeling of shame, like what will my colleagues think of me? How will they ever respect me after this? And people really worry about their relationships at work because of an event. And then of course it goes without saying, we work in a litigious environment and there's a fear of legal woes. There's also fears if I talk to anyone, what about HIPAA? What about confidentiality? And then I'll talk to you now a little bit about kind of how UCSF's Caring for the Caregiver Program was born. So back in 2016, in my patient safety role, I started to think a lot about all the hard cases. I was pulling people together around for our CAs and sitting at the table, sometimes watching some of our C-suite leaders facilitate the discussion. And I could tell from the faces around the room that people were really having a hard time. And some of those cases were particularly rough and realized that there was an opportunity here to much more meaningfully support people as opposed to sort of just saying, well, we have the faculty and staff assistance program and here's the phone number. So what we did was we brought together a multidisciplinary group of stakeholders and identified a whole lot of gaps at our organization. So basically what we realized was that the culture of support was extremely reactive. I really relied on the individual to seek out support. And so people just weren't getting support when there are errors or adverse events, they weren't reaching out because there's such a stigma to reaching out. And then the resources that we did have were super fragmented, not well-coordinated, available sort of nine to five, Monday through Friday, which really doesn't work for most people who work in healthcare and were actually offsite away from where people were practicing clinical medicine. And then at a lot of root cause analyses and other settings like MNNs, people were really emotional, but there wasn't really a systematic approach to asking people how they were really doing before diving into what happened and why it happened and how to prevent all that from happening again. And then the biggest gap we identified based on the literature and what we know to be true that people really wanna talk to a trusted peer, we just didn't have a peer support program. So we went on a roadshow to get buy-in from leadership and the front lines. We came up with our program objectives and marketing materials and built an internal website. And then we did have an inaugural training really focused on training physicians, staff, nurses, even some trainees that work in a lot of the high risk areas around UCSF and trained about 80 people initially. And then have continued to train more and more peer supporters over time. And then we also developed institutional models of support that are similar to those at other organizations. So created a way for people to be able to access numerous resources if that's what was needed. And then also created referral mechanisms because peer support might be appropriate initially, but someone might go on to need professional support after that. And then we also decided to bring Schwartz Rounds to UCSF, which some of you may be familiar with. It's really a grand round style format of discussion, but the focus is really on the impact of a patient case on the multidisciplinary team involved, or we bring together a multidisciplinary panel around a particular theme. So one example we brought folks together to talk about was the experience of using the End of Life Option Act and what it was like for them emotionally. We had one on what it was like to go through litigation, what it was like to care for patients with really challenging substance use disorders. And then to date, we've trained over 400 peer supporters across the organization from a wide variety of clinical backgrounds. And this just highlights our program mission. So really trying to make sure that people are supported through the experience of patient care in a proactive manner. We coordinate really carefully with our faculty and staff assistance programs, spiritual care services, and other resources. And then we've been working to sustain this peer support program for several years now. And then the other thing that I think is a really important aspect of our program's mission is to promote awareness of the emotional impact of patient care. So that's really started to become normalized throughout the organization. And so how it actually works is that there's a large group of people that hear about the hard things that happen around a really big place, but I'm sure this doesn't at all capture all of it. So our safety team, the managers on the units and in the practices, the service chief, sometimes the chairs, our risk managers, there's lots of people here about errors, adverse events, unanticipated outcomes, near misses. And they contact Caring for the Caregiver directly via, we have an email address set up and have started to make requests for support for people involved in a tough case, or sometimes we now actually get people referring themselves. And then basically what happens is our program manager, sometimes along with me and a couple other folks will help triage the request to identify the appropriate type of support. And we really try hard to match the individual in need with the appropriate peer. So if it's a critical care nurse, for example, we'll really try hard to match them with another critical care nurse, or if it's a ED provider, we'll try to figure out who the right provider is for that person to talk to. So really trying to match people appropriately based on what the need and situation seems to be. And then we also coordinate additional support via group debriefing, sometimes if a whole area is impacted. And sometimes we'll initially provide peer support, but what the person is experiencing and going through sometimes seems to also merit professional resources. And so then we'll tie them into the Faculty and Staff Assistance Program and a couple other professional support resources we have. And so these are just some examples of the kinds of requests we get and for what kinds of events we get requests for. So unexpected deaths, delayed or misdiagnoses, errors, especially from some of my procedural and surgical colleagues, because I think what you all do is really, really hard. And for a lot of my nurse colleagues, when there's a medication administration error, I think that's particularly challenging for them. More recently, especially in the spring, we built a lot of extra resources around COVID and then started to get quite a few requests that were COVID related. And then we get quite a few requests related to unanticipated outcomes involving trainees and have worked really closely with those leading graduate medical education efforts to develop peer support resources for residents. And so, it's very clear that I think the most desired form of support is from a respected colleague. And studies have shown that higher physical distress and lower institutional support are associated with turnover intent. And Jyothi encouraged me to say, not say perhaps, I think it's really true that programs that provide peer support will definitely contribute to less burnout and the adverse impact that burnout has on healthcare providers. So just a few words about starting a program at your organization, if you're thinking about it. I think it's really important to make a list of all the existing support resources and then better understand what the gaps are and why those might not be adequate. Identifying key stakeholders is super important. We included many of our social workers, our chaplains, a lot of people focused on different aspects of improving wellness. I think a proactive approach is key. I think relying on people to reach out for help is just essentially giving them another phone number or page or they're not gonna call. There has to be some mechanism to tie that outreach to the hard things that happen. And I can say, honestly, I've never gotten a response from someone that says, how did you know about that case of mine? At one end of the spectrum, I get a response saying, thanks so much for reaching out. I'm doing okay right now, but I appreciate knowing about the resources. And at the other end of the spectrum is, thank you so much for reaching out. I'd love to talk to someone. So I think being proactive is really important. You need some materials, either electronic or paper that you've developed that you can hand to people. Key executive sponsors are really important. I think starting with the high risk areas is a good idea. You'll develop local champions over time. And remember that some of this work is culture change and culture changes slowly, but I can say now doing this at UCSF for about three and a half years, I do think the culture is changing. I really see people figuring out how people are doing and suggesting that they get support and making sure that it happens. And that's a part of normalizing the need for it. And then you have to develop a peer support training. We initially started out with something that was about half a day, and then we're able to get it down to about two and a half hours and incorporate some basic communication skills and touches on a few things to really help people walk away with something concrete that they can build upon. There has to be some expectations for the folks who are willing to serve as peer supporters. We had to really think about how we were gonna manage the referrals. And then there's gotta be mechanisms that are established to refer people to other resources, especially when they need professional support. And then we also created ways for the peer supporters to debrief with one another and have organized a number of additional training opportunities for those who may be interested in becoming skilled at debriefings. And other skill building. And then I think the other last thing I'll say is that the program has to be protected and conversations have to be confidential. We tell our peer supporters not to take notes. We've worked with risk management to make sure this program is protected under the SAM law. So this is as our patient safety committee and our M&M process and really guide our peer supporters in terms of when they need to refer the person in need of support to risk management for advice or other groups for advice and have talked with them about the limits of their role as well, which I think is really important. So I will stop there. All right, thank you to our awesome panel of speakers for presenting all of that. So much resonated with me. I meant to say at the beginning for everybody who's participating in the webinar, tuning in, please type in in the Q&A any questions that you wanna have any of us answer. I really appreciated pointing out how at UCSF you have the peer support is available, but also proactive. Of course, any big events, adverse events, cases, all those get reviewed at our performance evaluation. And I think it's great to have somebody reach out before. I think all of us as physicians, but especially as surgeons as well, we're already self castigating if we've had a case that hasn't gone well and we're obsessing about it and thinking about it and just beating ourselves up. And of course we're going to review the case and do the root cause analysis. But I think getting us better equipped to do that first is awesome. I think for everybody else as well, I would say that I've personally benefited from just a more informal peer support, even outside of institution, just finding somebody that I trusted and admired that is available that I can text and say, hey, can we have a phone call or a face-to-face chat? I think that's incredibly helpful. So with the peer support program or in a more informal way, if you can have somebody that as something comes up or as you have a case you wanna talk about that you can talk to face-to-face or second best by phone or even by Zoom, that's immensely helpful. So I don't see any questions and answers or questions coming through in the question and answer panel. We'll give it maybe another minute for anybody who has tuned in that has a question. We'll also of course have resources. The packet for this webinar has several great references for people who wanna do further reading or find out more, or if they want resources, how to start a program at their institution, we'll have resources available as well after the talk. Jyoti, I have a quick question maybe for Dr. Gupta. One of the things, I have a colleague who's also on our wellness committee. She's a colleague of mine from residency and we're kind of buddies. We had a case where we both were consulted on the same case and it ended up being kind of a really bad situation. And I remember driving home that night and I gave her a call and we kind of did this informal debriefing. We didn't even know what we were doing. We're just trying to get home and de-stress. And we kind of in that conversation, she said, oh, I had a call from wellness about a year ago. Someone called and reached out to me because they knew I had a bad outcome with something and it was very helpful. And so we just kind of agreed to be each other's buddy or professional colleague kind of. And so is that a part of the structure at UC where you kind of ask, I mean, we've kind of implied it, but the question is, are we supposed to try to identify somebody, one or two short list of people where you can say, how are you doing? Well, what's going on? And then you kind of open that conversation up to what's been going on in your life to kind of preempt some of the other problems. I think what we do try to do is have some physicians trained in every discipline, especially in the procedural areas so that we really do have the ability for at least one person to be in that specialty or that area. And then I think the other piece we've started to think about more recently is I think people earlier on in their career, so potentially right out of training, are more vulnerable when hard things happen. And so figuring out a way to incorporate some aspect of this colleague support, it may not be a peer, it might even be someone a little further along who's had a similar experience and can normalize what the person's going through, but trying to figure out how to build this into mentorship a little bit because there's some overlap there. So the shorter answer is, I guess, yes, but maybe a little bit differently than that because it's such a big organization that things don't always happen organically in that way, although I wish they would. I'm gonna chime in to answer a question that came through, which I think is very appropriate. So one of the participants asks about these kinds of resources in a private practice setting, which is exactly what I'm in. I happen to have a connection to a university setting. I think, and it can be hard, it can be almost a little bit of trial and error. So I tried to connect with some people and I think you might reach out to another colleague who may honestly not be that helpful. So I had a colleague also about 10, 15 years ahead of me in practice that I reached out to and tried to talk about something. And I found that she actually made me feel worse. And so she wasn't the appropriate friend. She's also an orthopedic surgeon. She happens to be a woman. And I just thought that she didn't really, she just wasn't helpful. And I found this other colleague who happens to be male, who just was a lot more on the same wavelength and was really just relating to me and telling me how it is and just really gave me some great advice. I remember going to him after just dealing with an event and he said, you have to look at these things like compartmentalize them. So when you're dealing with this, deal with it when you have to deal with it, but don't let it carry over with you into the rest of your practice or how you are as a surgeon or to your home life. And really just try to do your best to deal with something when you have to deal with it and then put it in that box and then deal with it separately. And that was just one element of different advice I've gotten from him that was really helpful for me. So I think it's not quite as available as a university setting, but I think you do have to be a little bit more proactive and really try to think who is somebody who I relate to well that I trust and maybe strike out once or twice, but find somebody. And then when you do that can really be your go-to person. Okay, trying to figure out how to mark that as answered I hope that was that was helpful, please keep keep the questions coming if there's more more questions. I have a question to maybe to the panel will keep it alive. I'm almost challenged by how do you not make a maybe the Wellness Committee or the Wellness Center or peer support, you know, the way you frame it. You know at our institution, it seems like historically wellness has been punitive, you know, something happened. Now someone's calling you, you know, I have that same challenge when I have an ethics consult, right. I have to introduce myself as ethics, you know, and people feel like what I'm not unethical, why am I getting called so yeah being, I think the peer support I like this. This strategy and being more resource centered and available and training and having like goodwill ambassadors and different departments at least so one hospitalist and one pulmonologist or intensivist and then you can. I guess what I'm trying to say is, we still haven't figured out how to click on all cylinders with wellness not being punitive, you know this doctor's in trouble. Why don't we go and call and show him some support. And, yeah, that's the hard one, getting doctors to get to reach out and say they need help. I can give one quick example of, of how we sometimes do things and I got a call from a surgical colleague who was worried about his surgical colleague fairly early in his career who just had a really bad outcome. And from the sound of it, it felt to me this person would need both peer support and professional support, but me a hospitalist, a medical director of patient safety calling this person about their heart outcome was going to probably make them have their backup So I got the peer supporter figured out who is a surgeon, I got them an appointment that day at the faculty and staff assistance program and I called back the surgeon called me and said here are the resources. If you give them to your colleague, he will much more likely go and be accepting of them, and then here's my cell call me back if there's anything else we can do or we need to troubleshoot further. So I do think having that champion in that area, identified and known to people is really really helpful. I'm going to comment a little bit differently about it, which is, I feel like wellness is something that I see advertised at the grocery store right everything is is health and wellness now, it's a buzzword. And whenever I have an administrator say the word wellness to me I feel like they're going to offer me a yoga class, instead of fixing my electronic medical record. Right. And those are the real things that contribute to burn out. What Rahim said and really emphasized about these moral conflicts and ethical conflicts that lead to distress. It builds on a lot of what we know about the work of moral distress and people who are focused on this topic of your moral residue so when there is a mismatch between what you think you ought to do and what you're able to do is where the conflict arises. And when you actually are in a place that your values are being challenged and you can't execute what you want to do that is when we are at most at And so I just think that a yoga class is completely insufficient that's like offering me, you know, a latte when what I need is a five course dinner it's just not enough it's not what we need. And I think that the healthcare system has been looking for easy fixes because not because they don't recognize the gravity of the problem, but because they absolutely do when they know that they can't tackle it. And ultimately it is going to be up to us as physicians to tackle it and find a way forward. And I truly see this peer support movement as a pushback against it of us reclaiming and saying no, you're. This is what we need and you gave us yoga, you told me to download the call map, and then I'm not going to lose sleep over the fact that we're trying to figure out how to allocate ventilators amidst a mass casualty it's a slow rolling mass casualty event that's And my hope because I am no matter how many bad things happen a persistent Pollyanna optimist. I am hoping and honestly praying that this moment of coven is the moment that physicians, nurses apps, rise up together and reclaim our field and figure out how forward so that in 20 years, we're not still talking about burnout, about a system that's being opposed upon us, that is mismatching our values to what we're able to execute and do nobody went into medicine, because they wanted to see how many meaningful use clicks we all said. And I think almost all of us believe we wanted it because we wanted to be able to help people. And the burnout happens when we are obstructed from being able to do that, which I think that peer support and framing it from a moral ethical lens is so important, because that's where the distress comes. If I didn't care about my patient, I wouldn't have been freaking out about the less than perfect x ray. And that's what I always tell my residents, the ones who are really upset about the bad outcomes aren't the ones I worry about being good doctors, it's the ones who shrug and say whatever that I get really scared about whether or not I can train them because you can't train the caring. So, I, I will say as an aside I've been finding tremendous peer support and social media which I'm not much of a social media junkie. But there are some kind of closed physician groups which has become a peer support network and in some ways when you don't know the folks it's easier because the judgment is more divorced from your day to day which I think can be helpful. I just wanted to share with everybody another question that came through because I think it's quite relevant to what Dr. Humbert was just touching on the question is about recommendations for navigating systemic marginalization of doctors university system, and goes on to mention at the particular academic system they're at. There's pressure for the doctors to work more click more on the EMR and exactly offer sort of physician wellness with more snacks and coffee and a new faculty lounge. And then I do want to come back to this but I also want to add a bit to an answer I gave before about finding peer support resources, because Dr. Humbert touched on this as well. So, within Ruth Jackson it's something I've been very interested in is creating a peer support resource for people that may not have somebody right in their community, or want somebody who's also an orthopedic surgeon, such as myself to be a peer supporter. So, I think something like the women orthopedics Facebook group has that informally where it's a closed group where people do get some peer support that way. But it's something I've been looking to implement within Ruth Jackson to have people available to be peer supporters so that's something I would say just stay tuned, because I'd like to see that happen, not just on a social media outlet but have people like Ruth Jackson who want to be available to be a peer supporter on a not just a local basis but somebody who could be available remotely. And with that said, Dr. Humbert I'll let you address potentially this recommendations for addressing marginalization of doctors and the university system. I don't have a super satisfying answer, I can rail against the system but I don't have the solutions. What I will say from my perspective in terms of how I'm working to solve it. First off, I find that in the service of others I find my greatest renewal, whether it is medical service, whether it is always bringing the residents food on weekends which you know I always do because they enjoy it but more importantly it makes me feel good which is perhaps part of how I function. And then I think that we have some obligation to advance in the leadership structure because the only way to get our values out there is if we don't opt out of the leadership, and that you need to have physicians in those roles, guiding because we have the moral compass. We should be the people who are deciding how we are delivering our health care. I will say, I don't often feel like it's the physician administrators who are giving me the cheese sticks and telling me just yoga to do it. There's no one person who's perfect but there's a difference between being in the trenches and understanding how challenging these decisions are. And then when you'll have an administrator tell you to do something. One of my partners has had a great line about that's a line that only an administrator in medicine could ever make no physician has ever said that. So when people say those things instead of what I used to do which is take it on and say okay now how am I going to try and live and fit into their box. Instead evaluate statements that are being made when they're telling me how I need to reshift my moral compass and decide, is that a true north, or is that something that only someone who's never taken care of patients would ever tell me to do. And as soon as I reframe it in that way, it becomes really, really easy. So, you know, for better or worse we can always close on Dumbledore which is always choose to do what is right, rather than what is easy, but doing the easy thing that you're told to do up front, I think causes a lot more difficulty long term. All right, well I think we're running just a little bit past time so we'll have ways to connect afterwards if people had some unanswered questions. Thank you to AOFAS for hosting this making this happen providing the technology, and to all of my panelists speakers for your time and dedication. And with that being said, everybody have a good night. Thank you.

peer support

physicians

burnout

healthcare institutions

emotional support

career longevity

patient care

establishing peer support program

physician wellness