Good evening. On behalf of AOFAS, I want to welcome you to the third installment of the 2020 Physician Wellness Webinar Series presented in collaboration with the Ruth Jackson Orthopedic Society. Tonight's program, Second Victim Syndrome, will be moderated by Dr. Julie Bogue-Samora. Joining Dr. Samora is Dr. Michalis V. Hogan and Dr. Mary Kay McKelvey. You can find their full biographies and disclosures in the program document posted in the PRC. The 2020 Physician Wellness Series webinars are provided free to AOFAS, RJOS, and JRGOS members with funding by the Orthopedic Foot and Ankle Foundation, supported by grants from Wright Medical Group, ENVI. I'd like to run through a few housekeeping items before we kick off the presentation. Please make sure your speakers are turned on and that the volume is turned up. For technical assistance, you can reference the Help tab at any time. If you have any technical difficulties, your best bet is to close all your browsers and log back in the same way you did the first time. If you experience any buffering issues, please refresh your browser. Registered physician attendees may earn one hour of AMA, PRA, Category 1 CME credit by completing an evaluation in CME claim form at the end of the webinar. You can find the link to claim CME in the chat tab. You will also be sent an email with the instructions following the webinar. This webinar is being recorded and will be available in approximately one week. You will be able to watch the recorded version of this program at any time by visiting the Physician Resource Center at www.aofas.org. You are encouraged to ask questions during the presentations. To send your questions to the faculty, click on the Q&A tab on your navigation column. I will now turn the program over to the moderator, Dr. Samora, to begin. Thank you. All right. Thank you so much for that introduction, and we're really excited about talking today about Second Victim Syndrome, Coping with Complications, and Physician Wellness. I would like to express my gratitude to the American Orthopedic Foot and Ankle Society for their collegiality and willingness to collaborate on this Physician Wellness webinar series. I would also like to thank the American Orthopedic Foot and Ankle Society for their series. From my standpoint, I have no disclosures for my part of the talk, but as you've seen before, we do have all of our disclosures listed there. The objectives for this evening are to be able to define Second Victim Syndrome, to also develop coping mechanisms to address negative patient outcomes and perhaps some unhappy patients and families, and then to understand the importance of wellness for safe and high-quality care. The order of presentations tonight, I will start out giving really sort of the background of Second Victim Syndrome, and then Dr. Hogan will review sort of how to deal with those bad outcomes and those unhappy families, and then Dr. Mulcahy will finish us off with talking about really techniques to be having good wellness and really to try to prevent burnout in medicine. Throughout this conversation, feel free to write some questions in the chat box, but we'll also have a Q&A at the end, and we can all answer your questions. To give you some background on our excellent speakers tonight, Dr. Hogan is the Associate Professor at the Department of Orthopedic Surgery at UPMC, where he is also Vice Chair of Education and the Residency Program Director. As listed here, you can see he also has very many other leadership positions. Dr. Mary Mulcahy is Associate Professor of the Department of Orthopedic Surgery at Tulane University, where she's also Director of the Women's Sports Medicine Program and Co-Director of the Orthopedic Surgery Clerkship. So I'm looking forward to hearing what both of these great speakers have to share with us this evening. To start us off, we're all very well versed with the publication in 1999 by the Institute of Medicine to Err is Human. It found that about 100,000 deaths per year were due to medical errors. In this report, they found that medical errors occurred in as high as 18% of hospital admissions. Since that time, there have been further studies that have shown that up to 33% of hospitalized patients may experience an adverse event. And in fact, medical errors are the third leading cause of death, accounting for almost 440,000 annual fatalities. So clearly, medical errors occur. However, in medicine, perfectionism is a common trait and often expected of all health care providers. We know perfectionists strive toward excellence, have a deep sense of responsibility, set excessively high standards, and really for perfectionists, making mistakes is not an option. If an error occurs, perfectionists may view it as a failure of character and may experience doubt, guilt, and an exaggerated sense of responsibility. We go in medicine to improve the lives of others, and when a patient is inadvertently harmed in the care process, this can be very traumatizing to the care providers. The term second victim was first utilized in an editorial in the British Medical Journal by Albert Wu in 2000. In this editorial, he described as an intern witnessing a fellow resident physician receive universal backlash because this resident had failed to identify EKG signs of pericardial tamponade, which eventually required an emergent surgery. The news of this resident's lapse had spread rapidly, and the case was tried repeatedly before an incredulous jury of peers who all returned the summary judgment of incompetence. So Wu describes the second victim as the provider who has made a mistake that led to harm, who then has to come to terms with individual failure. First term is the patient and family, and the third victim has been referred to as the healthcare organization. Now this slide is very busy, but I'm going to actually read every word. This is a really nice definition of second victim syndrome, or you might hear the term second victim phenomenon. Second victims are healthcare providers who are involved in an unanticipated adverse patient event, in a medical error, or a patient-related injury, and becomes victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome, and many feel as though they have failed the patient, second-guessing their clinical skills and knowledge base. Now there are a lot of concerns with the term victim. Victim stems from the Latin root victima, which is sacrificial animal. More contemporary definitions include one who is harmed by another, an aggrieved or disadvantaged party in a crime, a person who suffers injury, loss, or damage, or an unfortunate person who suffers from a disaster or other adverse circumstance. The concern with this term victim is that it may connote passivity or a powerlessness. Some argue that this term stigmatizes those involved. Healthcare providers may not be comfortable being labeled a victim, and therefore may be unlikely to seek help. Now there have been some other terms suggested, such as secondary trauma, wounded caregiver, and wounded healer, but none of these have gained traction. So for now, we're stuck with the term second victim. Really, anybody who is in the healthcare environment, who is involved in a medical error or a bad outcome that suffers mental and emotional distress, can be a second victim. These medical errors can have considerable negative effects of the well-being of the healthcare providers, and this has been shown in many studies, which I'll review. Some of the negative effects include guilt, shame, anxiety, fear. These healthcare providers can also develop post-traumatic stress syndrome, can have poor quality of life at work and at home, and can even develop suicidality. Healthcare workers that have been exposed to a medical error or been involved with a medical error can experience flashbacks to that event, nightmares, and avoidance of similar situations. Involvement in these unintentional errors can have lasting impacts as well, including a lack of concentration, burnout, depression, poor memory, decreased clinical confidence, and impaired work performance. There are physicians who have even left the field due to this second victim effect. In a large study of more than 3,000 physicians who were surveyed about their response to medical errors, 60% had increased anxiety about future errors, 40-plus percent had a loss of confidence, sleeping difficulties, reduced job satisfaction, and 13% worried about their reputation. Only 10% of these more than 3,000 physicians felt that their healthcare organizations adequately supported them in coping with error-related stress. This is a study of just surgeons out of Boston who had been involved in an intraoperative adverse event, and surgeons who had had this intraoperative adverse event felt sadness, anxiety, anger, guilt, shame. Very few had no emotions experienced after this one of these events. A large systematic review found that surgical complications negatively impact surgeons emotionally, with adverse consequences in not only their professional lives, but also their personal lives well after the incident had occurred. In another study, surgeons have reported physical symptoms, including sweating, heart pounding, headache, physical tension, which can affect their surgical technique, as some had reported experiencing tremors, clumsiness, and even low dexterity. In a large study of anesthesiologists, almost 90% who had been involved in one anticipated death or a serious injury in a perioperative event required time to recover emotionally. 70% experienced guilt, anxiety, and reliving of the event. Almost 20% acknowledged never having fully recovered from that event, and 12% considered a career change. In this study by Scott and colleagues in 2009, they looked at the natural history of recovery of health care providers who had been second victims. And this study reminds me very much of the study of grief, where we learned the stages of grief in med school. And they really reviewed kind of these separate stages of second victim syndrome. And I'll review these briefly. So the first stage is really that immediate sort of aftermath of the event. So there's confusion, turmoil. You move on to sort of these intrusive reflections where you replay the event in your head. You can get angry for any reason, have a loss of confidence. You have these feelings of isolation and certainly lots of self-doubt. Stage three is sort of the return of the personal integrity, where a physician tries to reintegrate back into professional life. Stage four is the enduring of the inquisition, which we can all relate to this. RCAs, MCAs, peer review, risk management, M&M, all focused on this event. And in this time, it can be a very scary time, a very anxiety-producing time, because you can worry about malpractice, licensure, loss of privileges. And then stage five is obtaining emotional first aid, where we're really trying to reach out to others. And sometimes others aren't sure how to help you. Surgeons are known to very infrequently use employee assistance programs and prefer, if there's any support that they seek out, peer support. And some may seek external professional support, such as a psychologist or a psychiatrist outside of the institution, but many often suffer in silence. The last stage of second victim syndrome is moving on. And this is really the cumulative effect of these complications, and it influences your personal self-worth. And the way Scott describes closure is three options. Option number one is you leave. Option number two is you stay and you cope. And option number three is you actually learn and grow. The concern with coping is that many are truly suffering in silence. They're losing the joy of practice. They're continuing to carry emotional baggage. And what these authors found is that those physicians that were able to learn and grow were actually able to derive something positive from that experience. In a very similar study, just looking at surgeons, Liu and colleagues basically described four stages, the kick, the fall, the recovery, and the long-term impact. The kick is very much like the same stage that Scott and colleagues described with that visceral blow to the core, the physiological signs of anxiety and stress, feelings of failure and self-doubt. The fall, where everything is really spiraling out of control. You've got this sense that you need to right the ship, but you're not quite sure how to do that. Everything is enveloped in a dark cloak. The third stage is the recovery, where you get this lifting of the cloud and you sort of start to develop these coping mechanisms. And then the long-term impact is very similar to the previous study that I referenced. And this study found that many surgeons actually restricted the scope of their practice, and some retired completely after these types of events. There are, in fact, risk factors for developing second syndrome, including being burned out to begin with. Residents certainly are at risk. Less experienced surgeons, surgeons who may feel unrewarded or overwhelmed, female surgeons, and finally those who perceive an imbalance between career, family, and personal growth. Trainees are not immune and certainly demonstrate distress from these self-perceived or true medical errors that are their own. And there is a clear association between medical error and resident quality of life, fatigue, burnout, empathy, and symptoms of depression. Residents do perceive greater responsibility and possible consequences to their own medical errors. And in this separate study, 80% of residents felt remorse, 80% felt anger, 70% felt guilt, and 60% felt inadequacy after these events. And really a scary finding is that almost 70% of residents who had reported an error had a positive screen for depression. Now how people respond to these events or mistakes is different. Some respond defensively, blaming the system, blaming the patient, blaming other members of the medical team, hiding the mistake, or pretending that nothing happened in the first place. Those that can accept responsibility for their mistakes are more likely to make constructive changes in their practice. We know that physicians are rarely using medical, sorry, mental health services and often simply bear the burden by themselves. Some find it difficult to talk to colleagues about their mistakes, feeling vulnerable, but healthcare providers do need personal validation, reassurance, and professional reaffirmation. The stress of medical errors may further exacerbate risks of depression, alcohol or drug abuse, and even suicide. Interestingly, there's not much data on this, but perhaps there are some differential effects from the system with regard to medical error. So in this one study that's actually not published, but it's a working paper, in that women surgeons were found to have greater clinical ramifications for the same exact mistakes as men. So what they found is that after a patient death, referrals for the woman surgeon who was involved in that fell by 34%, with very minimal impact on male surgeons that had experienced a patient death. So something to look forward to as far as getting some more data in the future. Certainly there are lots of options, and Dr. Hogan will talk about a lot of these, but I'll sort of scratch the surface. This is a nice study by Robertson and Long, published in 2017, that really talks about six major things. Support and counseling, analyzing and learning from the mistake, openly discussing mistakes, focusing on the system, enhancing provider wellness, and implementing culture changes are all important to focus on second victim syndrome. Adequate support has been shown to reduce the distress associated with second victim syndrome. While negative institutional mindsets and lack of support does foster those undesirable effects I talked about earlier. Among the various types of support available, peer support is becoming best practice. And for those who have experienced second victim syndrome, peer support was identified as the desired resource. In this similar study that I referenced earlier on the intraoperative adverse events, surgeons described colleagues as being their number one support system, followed closely by family members. So really having someone to talk to about this event was really helpful for coping. There are certainly barriers to support, a lack of awareness of what mechanisms might be available, time constraints, concerns about discovery, and certainly in this country there's still a stigma associated with mental health issues. Very few surgeons in another study were even aware of potential support groups and a minority were willing to seek professional help to deal with these stresses. In a survey on the impact of stress on surgical performance, all surgeon participants reported that they never received any training on how to cope. In this study by Goldberg and colleagues, they did provide some mechanisms to cope with these mistakes. Number one, accept the responsibility. Number two, talk with others, discuss these with your colleagues. Number three, disclose and apologize to the patient and the family. Number four, make changes designed to reduce future errors. And finally, and loftily I should say, work locally and nationally to try to change the culture regarding the management of medical mistakes. Logically analyzing the mistake and learning from it can also help with emotional healing. Debriefing after an adverse event, talking with colleagues has been found to be very useful to help the responses. Disclosing errors to patients can help and then analyzing and learning from mistakes might not only help from a coping standpoint, but can actually help to improve future patient safety and the system at large. Physicians have shown time and time again that the organizational responses to medical errors can be hostile, threatening, isolating, or fundamentally flawed. We know that MNM has not traditionally been set up to support the physician. Although it has come a long way in trying to, you know, focus on improvements of the system, there is still some shame and blame that's seen in some of the MNMs today. There is a continued opportunity to emphasize the message that most errors are a natural consequence of being human and certainly there are system issues that support that error to occur. Several investigations have shown that there is a lack of institutional support for second victims. In that large survey of more than 3,000 physicians that I referenced earlier, about more than 80% found that they wished they had counseling but did not see the institution support them. And it's important to develop this culture of support rather than blame and punishment. Although many failures are systems-based, individual providers are still often treated with blame and abandonment. MNM process or MNM conferences, peer review processes, licensing, credentialing are all really traditionally evaluating the individual, which can single out providers and make them feel as though they have failed personally. We are in the process of trying to get ACS certification at our hospital and we've really changed the way we've done our MNM conferences. And this children's surgical verification program does include a standardized review of errors and really focuses on improving quality rather than assigning blame and I think this is a much better system. Now burnout correlates with a higher rate of medical malpractice, a higher rate of medical errors. So we really need to focus on burnout, which Dr. Mulcahy will talk about in a few minutes. Work unit safety grades have been strongly and independently associated with perceived major medical errors. Fostering an environment in which errors are openly acknowledged and systematically analyzed is really critically important. Continuous QI efforts should include policies to address mistakes and regular discussions of medical errors in formal conferences, including those with trainees, is really important and it's important to dispel this false notion of perfectionism because none of us are perfect. We should have a training curricula really to address medical mistakes and how to cope with them. And then again, providing this nurturing work and learning environment of support rather than shame and blame. This summer I experienced a very, very unhappy family with a very poor outcome and it was a really hard time for me. And so I sought out advice from many surgeons at my hospital and I sort of came up with the top 10 pieces of advice from people that had spoken with me. And so I'm sharing that with you tonight as sort of my take home for this talk. Number one, acknowledge the complication. It happened. Grieve. This is not a sign of weakness, but it's a healthy response. Go to someone you trust and share your story. Check your emotional state. Are you sleeping properly? Are you eating right? Are you yelling at people for no reason? This event does not define you or your surgical ability. If you have a bad complication and have cases that follow, so for example, you have an intraoperative death, which fortunately we don't have that in orthopedics that often. Stop for the day. Cancel the rest of the cases. Call legal. Make sure they know what happened or that this family is upset. Share the event with your chief or your chair. Talk with the family after you talk with legal. Be honest and have a low threshold for saying you're sorry. Offer for them to get a second opinion. If you've sort of lost that trust, it's really important that they know that there are other people that they can talk to as well. So in conclusion, second victim syndrome is common amongst healthcare providers. Significant negative effects occur due to second victim syndrome. Do not hesitate to seek out colleagues and utilize the support systems available to help ameliorate these negative effects and try to promote a culture to openly discuss errors in a blame-free and safe environment and finally encourage that nurturing work and learning environment focused on wellness. I would like to turn the mic over to Dr. Hogan who will provide us with some more knowledge. Thank you. Thanks, Dr. Samara. Great talk and great follow-up as well to a very well-written AOA focus piece that you recently did on second victim syndrome. And so I'm going to prepare to share my screen here. And And so just so I have no disclosures and a special thanks to our GME Wellness Committee that I work with here at UPMC and Pitt. And so a few things. And so as we, the air is human, the article that many of us are aware of and a number of the other, the literature really looking at physicians and the impact of adverse events, you know, facing our mistakes, coping with fallibility, do house officers learn from their mistakes? And obviously the medical error of the second victim. And just again, reiterating the second victim recovery trajectory of the chaos and accident response versus intrusive reflections and then restoring personal integrity is that middle stage. And then enduring that inquisition, obtaining emotional first aid and moving on. And it really is that discussion of thriving, surviving or dropping out. And often with my partners to myself and particularly to my resident trainees, we talk about surviving to thrive. And with that, we wanna be mindful. And so Dr. Samora mentioned these points, but they're really key. And you think about the physician's involvement of the second victim study, near miss in 7%, minor errors, 36% and serious errors in 57%. It's considerable. And the impact and particularly as we go down to 80% report that they would be interested in receiving a report, which is positive. The initial response often is not to put themselves on an island. And 90% reported their healthcare organizations did not adequately support them. And this is really what has driven a lot of the recent focus on reinforcing these support resources across healthcare institutions. Now, reasons for seeking support, fatigue, the interpersonal conflicts at work, the burnout, mental illness and family members, personal life struggles, all the way down through the legal situations and that's where people really start under, when it's legal, they say, oh, you know what? I probably would get help. But there's a spectrum here. And then when we think about the emotional impact of an index case, right? They reliving the event. All of us can remember the first really bad event we had as a resident trainee. Also the first one you have in practice. And it is a nature of our field and our craft and our effort to help others that this will occur. But we still experience this, the guilt, the fear of litigation, depression, the sleeplessness, the judgment of your colleagues, a huge one. And the other points that were mentioned here. And so the time to emotional recovery after the index case, the spectrum that when we take this approach and we try not to do this, I know I do, I'm saying, you know what? Just buckle down, this too shall pass. Yes, that's not a bad way to try to motivate. However, it doesn't necessarily pass as quickly as you can. It's not like, you know, they tell the quarterback when you throw an interception, get back in there the next drive. It's difficult, it's challenging. You have a very small percentage that are not affected. But now we're wondering, is that a problem? Should there be, there should be some level of coping and evaluation and self-evaluation and introspection that goes along with these unfortunate challenges. But many never fully recover. When we look at the impact of the quality of the subsequent care, that is where we want to really focus in on of like, you know what, what can we do so that you can be your best self for your patients to provide the best care for your patients? 74% believe that the time off should have been offered in the aftermath of perioperative catastrophe. And the point that Dr. Samora made in that, you know what? You shouldn't feel ashamed or intimidated to just say, we need to have a pause, we need to step back, come back to have our best self the next day or another scenario. Only 7% were actually given time off. And this is definitely a difficult and challenging in our field in crowd and horse peak surgery. So what do people need? I mean, there are a litany of things that people need. And the question is, how can you in that moment help contribute to meeting those needs? And sometimes it's as simple as a single word. And so second victims want, they want to feel appreciated, respected, less alone. Most individuals, again, do not want to be on an island. Valued, understood and supported. Last but not least, to remain a trusted member of the team. And that goes to the real strength of colleagues really helping lift you up, patting you on the back and saying, hey, you can do this. Barriers to seeking help. Again, feeling as though individuals will not understand. Problems are not important. Costs, using services, thinking that they're weak, intimidation. But what's really interesting from this particular survey is individuals reporting the lack of time, the hustle and bustle of healthcare delivery and what we provide and what we do on a day-to-day basis. And the feeling as though, you know what? I can't take that time off. I think all of us are experiencing this now even in the midst of COVID and our pandemic. I still have residents who essentially call me to get permission not to come to work, even if they're expressing potential symptoms. It's amazing, but that is a learned behavior and one that before was galvanized, but that is not the most appropriate for all times. And this feeling of lack of time off. And so majority of individuals will not need formal intervention, particularly if they have great peer support. And so they don't need more formal intervention if they have that peer support. However, when in doubt, seek assistance and supervision. I always really try to load the boat with consent and permission of my trainees or partners or colleagues and for myself. Limits to confidentiality, there are always concerns. We work as best we can to maintain that and the programs are within our respective institution. And I'm sure others really works to protect that. The only other thing outside of that is danger to self and others and risk in the workplace and crimes against children. I'm very transparent. As a program director, we had a particular resident one time who actually said they thought they were gonna hurt themselves and then tried to peel it back as it was a joke. And I said, well, it's not a joke. And so since it's not, we're gonna take some pauses here and work together on what we can do to help you, help one another and learn together. And so mirroring techniques. The restatement approach, and these are some things that we use here that I've had good success with, takes the person's words and restates them in the phrase to where you wish to inquire, emphasize. It demonstrates being concerned and really listening. And that's very important. Paraphrasing, simply summarizing in their own words are the main points for the person in crisis. This can help. So in your own words, sounds like, and it's okay to tell them, sounds like you're really angry. And that's the reflection of emotion and not disregarding the emotions that are actually being displayed to you, particularly as a leader and someone that they're reaching out to as a confidant, whether it be a colleague, someone who has a status respectfully in the ranking below you or above you and speaking with them. You're building rapport. And this is an approach of assisting individuals called the SAFER model. And it really involves a stabilizing. You can introduce, meet the basic needs, reduce the impact of the challenge, acknowledge the crisis, however, validate, provide reassurance, facilitate understanding, acceptance of reactions are understandable, okay? And encourage effective coping. Together, you develop a plan to address things and recovery or referral is always appropriate. And it facilitates access to the continued care if needed. So a little bit on my approach as a program director, and this is purely what has been developed that I've developed from mentors guiding me in this capacity. So really look to engage. Don't, do not shy away. You're in that position for a reason and you're a colleague and peer to someone whether you're their program director or superior or not. And challenges that go away by themselves usually come back by themselves and often when least convenient. My former chairman, Kayla Lawrence, used to say this regularly, which meant, you know, really work to engage and address the issue. Listen to understand versus listening to respond. This is a hard one and a challenging one, particularly for type A individuals of which many orthopedic surgeons are, even if they don't believe they are. And listening to understand someone's position and perspective is totally different than listening in preparation for a response. Again, I really work to load the boat with those who will support. I ask for agreement and consent to engage our residency coordinator and my associate program director. And at the beginning of each academic year, we talk through this with our respective residency coordinators and say, look, as residents may come to them with challenges, asking them if they are okay with engaging the program director and in what capacity and we go from there. Focus on facilitating progress, not really dwelling on the past other than to address the challenge that occurred in the unfortunate scenario. And reinforce that you may be best apart, but really in a better together approach. And in my experience, this facilitates that feedback and continuous loop of communication that you can have with your colleague, your peer or a surgical trainee and future practicing colleague. And regular check-ins, some, and when things are also stable, some, it's a saying, you really want to be engaged and have a plan outside the heat of battle. If the only time you're really engaging and checking in occasionally with your peers and others is when things are going badly, you will essentially, your environment and culture will become that, that there are only conversations, there are only discussions when things are falling apart or in a bad space. And so regular check-ins, even very small now with active communication is something I strongly encourage. And so, and in the end, remember what's important, in particular when you're in positions to influence others and guide others, do not be afraid to shy away from your auspices and your interests. We all put up walls and barriers to protect our private lives and our personal interests, but sometimes those small steps and letting individuals know what's important to you will actually weigh very heavily in the positive when real challenges come along. So thank you. And I will now defer the floor to Dr. McKay. Thank you. Great, thank you so much. So I will share my screen too. Great. Thank you very much, Julie and McAuliffe. Those talks were excellent. And it's a huge honor for me to be here and be able to give this talk to the group as well. So I'm gonna be focusing on avoiding burnout and maintaining physician wellness. These are my disclosures, none of which are directly relevant to this talk. As an overview, I'm gonna touch on some of the basics of burnout and the implications of suffering from burnout. I'll touch on some of the specifics related to burnout in medicine and orthopedics, and then really emphasize some techniques that we can use for managing and improving physician wellness. So burnout is a syndrome of emotional exhaustion, depersonalization, and reduced sense of personal accomplishment that can occur commonly in individuals who work in human services. It's often caused by long-term involvement in situations that are emotionally demanding. There are three components of burnout. So the first is emotional exhaustion. This is low physical and emotional energy levels where you start to say things like, I'm not sure how much longer I can keep going like this. Depersonalization refers to a detached cynical view of patients and colleagues. And this is where you're not emotionally available. The final component is a perceived lack of personal accomplishment, where you doubt the meaning and quality of your work and start to say things like, what's the use? My work really doesn't serve a purpose anyway. There are many contributing factors, including work overload, a lack of control, insufficient rewards for the hard work that's being done, and perhaps a lack of sense of community or fairness, and sometimes conflicting values. There are many, many consequences for the individual, including physical exhaustion and poor judgment, impaired relationships with patients, colleagues, and potentially this can even get to your family. Decreased quality of medical care, and certainly that's something we're very concerned about. Decreased effectiveness and productivity and decreased overall quality of life. There are many associated health problems as well, including headaches, insomnia, some GI disorders, respiratory illness, critically cardiovascular disease, emotional illnesses, which we've touched on, and an elevated rate of substance abuse, which can lead to suicidal ideation as well. There are also consequences for the employer or institution, including a high rate of employee turnover, absenteeism, poor job performance, and negative attitudes that can actually also affect other employees. This concept of energy account is very important. So we withdraw energy with our activities of life and our medical practice. We deposit energy with rest and rebalance. There are actually three types of energy accounts. So the first is the physical energy. This is where we take care of our physical body with rest, exercise, and nutrition. There's also emotional energy, where we maintain healthy relationships with the people we love. And McCall has touched on this. Recharging here is essential. And then there's spiritual energy, where you regularly connect with your personal sense of purpose. Now, importantly, if this account is drained, you may have trouble seeing a reason to carry on. Now, another important concept is, if you dip into a negative account balance here, the account doesn't close, right? This is not like a bank account. You just keep working, even though the energy account is depleted. But it's important for us to know, right? You can't give what you ain't got, right? You can't keep working and you can't keep giving that same amount of effort and energy and quality care when you don't have any energy. Positive energy balance is absolutely critical for our leadership skills, providing high quality patient care and empathy, and having skills as a spouse and parent. So we really have a moral imperative to keep our accounts in a positive balance. In terms of burnout in physicians, there are five main causes. So certainly the practice of clinical medicine, it is a high stress combination of great responsibility and very little control. We learn to cope with this though. Your specific job can also influence burnout, call schedule, compensation, local healthcare politics. There can be personality clashes in your department. Having a life, right? We are not taught life balance skills in medical education. We learn and practice ignoring our physical, emotional and spiritual needs. Leadership skills of our immediate supervisors can absolutely affect our work satisfaction and stress levels. And then the conditioning of our medical education, right? We define the traits of a successful physician as being a workaholic, a superhero and perfectionist and a lone ranger, right? Somebody who can do everything himself or herself. There are two prime directives in medicine. The patient comes first, right? This is natural, necessary, and it's a very healthy truth when we are with patients. But importantly, if you don't put yourself first when you're not with patients, burnout is absolutely inevitable. The other is to never show weakness, right? This is never stated. It is deeply unconscious and incredibly powerful. For burnout in medicine, there was a 2020 National Physician Burnout and Suicide Report that noted 42% of physicians reported experiencing burnout, which is down slightly from 46% in 2019. The main reported cause was administrative burden. The specialties that reported high burnout rates have been fairly consistent over the past five years. And at the top there, you see urology, neurology and nephrology. Orthopedics is down towards the bottom at 34%. Female physicians reported burnout at higher rates and mid-career physicians reported the highest stress and emotional exhaustion. In terms of orthopedics, this is I think is an important study to highlight. It was a study from JBJS in 2007, where they wanted to determine the prevalence and severity of burnout among orthopedic leaders in the United States. They surveyed past current and acting chairs and program directors from academic programs in the United States. There was a 69% response rate, which is really incredible. And the highest stressors identified were excessive workload, increasing overhead and departmental budget deficits. In terms of chairs and chiefs, about 36% had the highest level of emotional exhaustion. 27% had the highest level of depersonalization. Program directors of the program directors, 52% had the highest level of emotional exhaustion and 24% had the highest level of depersonalization. Only 13% of respondents indicated that their institution had support groups for chairs or program directors. And many respondents felt that they had little or no control over their personal lives and that their professional life would get worse over the next several years. In the discussion and conclusion, they noted that peer support is very important. This reduces the negative impact on both occupational and personal stress. But it's important to have workshops and presentations for all levels of the orthopedic community and to encourage active participation. They also noted that it's critical that we take regular pit stops, right? That we take a breath and recharge and practice good self-control in terms of developing awareness of increasing tension and getting toward the edge. They also emphasized the need to protect your investment, right? You are the most important investment and asset that you have. So it is critical to take good care of yourself and your loved ones. They also noted that we need to pay attention to how you talk to yourself, right? This can be the leading edge to how we act and behave. So it's important to talk constructively and positively. And finally, burn hot, but stay cool, right? Take your work seriously, but do not take yourself too seriously. In terms of promoting health and wellness, there are many things that we can try to do to reduce physician burnout, right? Trying to create an absence of role conflict, a sense of fair treatment and positive social support, creating appropriate financial, institutional and social rewards and proper alignment between the values of an individual and his or her workplace. This study is from 2017, where they wanted to analyze and evaluate the efficacy of burnout reduction interventions for physicians and compare the efficacy of interventions with different characteristics, including physician-directed versus organization-directed, the length of program or intervention and primary versus secondary care settings. They found small but significant reductions in burnout scores. And when doing subgroup analyses, they found better efficacy with organization-directed versus physician-directed interventions. So the authors concluded that current burnout interventions are associated with small but significant benefits and that benefits can be augmented through organization-directed action to adopt the intervention or program. They also noted that evidence supports that burnout is an organization-wide problem rather than a physician problem. So in terms of specific techniques, right, to promote health and wellness, things like a relaxing activity, exercising, making sure we get enough sleep and practicing mindfulness can all help. And I'm going to expand on these. So there are a variety of health benefits that have been attributed to practicing meditation, including reduced inflammatory response caused by stress, decreased stress, especially among individuals with a high level of stress, and then decreased depression. Also, experience in meditation may cultivate more creative problem solving. And finally, it helps individuals fall asleep sooner and stay asleep longer compared to those who do not meditate. Importantly, meditating can be practiced anywhere. Sleep, sleep we know is absolutely critical and I think we'd all admit that we don't get enough sleep, but sleep deprivation can have damaging consequences to health and wellbeing. The quality of sleep is impacted by it. It is impacted by health, relationships, security, community, and our overall environment. And we know that good sleep can decrease stress. It improves our mood and reduces the risk of chronic illness and helps enhance concentration. Mindfulness is also a really important and effective technique. So this is the act of focusing on your breath flow and being intensely aware of what you're sensing and feeling at every moment without interpretation or judgment. This improves your wellbeing, physical health and mental health. And this study is also a recent study where they wanted to determine if a mindfulness app can reduce physician anxiety. They also wanted to assess whether burnout and anxiety are correlated among physicians and to see if mindfulness apps might also decrease the risk of burnout. They found that anxiety correlated with burnout and that app-based mindfulness training showed a significant reduction in anxiety and burnout with regard to anxiety scores and also cynicism and emotional exhaustion. They therefore concluded that app-based mindfulness tools may be effective at reducing anxiety and burnout symptoms among physicians, but that research on larger populations of physicians is needed. And then touching on peer support for second victim syndrome, which Dr. Samora and Hogan have explained very well in their previous talks as well. But this is a recent study where the authors wanted to create a second victim peer support program for surgeons and surgical trainees. They wanted to evaluate the impact on all participants after a year using an anonymous, qualitative and quantitative survey. They had a five-step design so they created a conceptual framework. They had peer supporter choice, peer supporter training and they identified major adverse events. They also then planned for systematic intervention. So they found there were 47 outreach interventions in total during that one year period. The adverse events primarily included major intraoperative complications and unexpected patient deaths following surgical intervention. The peer support was conducted primarily via face-to-face interactions, email or via phone calls. In terms of participant survey responses, 89% reported satisfaction with program confidentiality, 70% reported that the program offered a safe and trusting environment, 80% were satisfied with intervention timeliness and 80% reported a positive impact in their respective surgical departments. So they concluded that the one-year experience suggests that the program was effectively utilized and well-received by surgical trainees and surgeons. And that implementation at other medical centers is really needed to determine overall generalizability. So in summary, burnout is incredibly common. We do need to remember that concept of the energy account and that we need to try to maintain a positive energy so that we can function effectively both at work and at home. And that focusing on maintaining health and wellness can be accomplished by several techniques, including meditation, yoga, physical activity, sleeping well and practicing mindfulness. So thank you very much for your attention. I'd be happy to answer any questions as part of the discussion. Great, great talk, Dr. Mulcahy. Dr. Hogan, I have a question for you. This is gonna be a couple of cases for you both. So Dr. Hogan, you have a resident that scrubs into one of your cases and happens to say, oh, hey, did you hear what happened to Dr. Smith? And you say, oh, I don't know. you say, no, I don't know what happened to Dr. Smith. And Dr. Smith is one of your junior partners, been in practice for two years, hasn't sat for their boards yet. But apparently Dr. Smith, in one of the routine cases they were doing, cut the perineal nerve. What is your role as a more senior surgeon, knowing you have this junior surgeon that just had this really devastating interoperative event and they didn't tell you directly? What'd you do with that information? So I'll tell you, I mean, my approach, you may not follow all of the textbook rules here, even some of the things I just mentioned. Most of my partners and colleagues know I really approach, I'm kind of an open book with confidentiality, of course. And I'm one of the believers of, as a program director, when my associate was appointed, I said, no one mentioned something around the program director by accident. It doesn't exist. It's unfortunate. If they want that, it's almost like reporting. They specifically say, I want this on the record or off the record. If it is just teased or like a soft pitch out there, I don't try to hit a home run and then scrub out and go chase down my partner, but I will actually do a check-in. I'll just kind of give a call vaguely and say, hey, how are things going? I won't necessarily do it that day. I'll kind of circle around to it slowly or find a way to put myself in that person's direction in some way. And I also will take into that account of that, what their demeanor has been up to that point, right? If we have an open relationship, I just got to say, hey, how are things going? And just try to serve as a resource. And I'll do that several times before just saying, hey, what happened with that nerve the other day or in that case and take it from there. And often I'll also ask the residents. They are an interesting, how I would say bag of knowledge or at least, I won't say knowledge, but they are definitely a bag of gossip that actually trends from OR to OR that we all know. So I was trying to get a feel from them, like, oh, really? And try to fill it out. But I definitely want to be available for that individual to support them and help them develop with those challenges because we've all been there. Perfect. Dr. Mulcahy, if this same scenario happened in your neck of the woods, how would you approach that to your junior partner? Yeah, I echo a lot of the sentiments that McCall has just expressed. I think the first thing is to demonstrate support, like offer support to the colleague. I mean, we all have separate complications. And as we kind of all touched on in our individual talks, having support from your colleagues is absolutely critical to get through this and emphasize areas for improvement, things that you can learn from that. And then just trying to understand what happened, like what was encountered during that situation, both good and bad, and how could it be prevented in the future? And I think also when you're having that discussion with them, sort of making your junior partner understand too that similar things have happened to you and that they're not alone in that situation. Yeah, so it's funny. I used to think that as orthopedic surgeons, we were all immune to burnout. If you looked at the studies back in the day, we are all the happiest of all the specialties. And now if you look, pretty much every physician in every specialty is at risk for burnout. Dr. Mulcahy, what are some of your techniques to really combat burnout? And what would you recommend to say your residents as a program director? That's an excellent question. For me personally, exercising is what gets me through and enables me to do really everything else that I do. So I set that as a priority and we'll put that above many other things. So I exercise a lot. I think that that's what gives me most of my energy to be quite honest. And in terms of giving advice to residents or other colleagues, I would say just identify whatever it is that makes you happy, that you enjoy doing and make sure that you make time for that because that's what helps you recharge and enables you to do the other things, whether it's with regard to patient care or administrative type things, research, et cetera. As long as you're doing the thing that really makes you happy, it will enable you to do the other things well. You will also be able to do that very well. And what if your resident says, Dr. Mulcahy, nothing makes me happy, nothing. What do you do with that? Ooh, that's a difficult situation. I would encourage them to at least identify some time where they're not doing work-related things. So whether it's go out and have a cup of coffee, sit and watch a show, talk to some of your co-residents and just take some time away from anything that is work-related. I think that's most critical. Now, when do you pull the trigger and get them some professional help? Because if someone says to me, nothing makes me happy, that's a big red flag and my shackles go up on the back of my neck. And what's your obligation as the faculty for a trainee in that situation? Yeah, that is an excellent point too. And I think that we touched on a lot in these talks today too, that we as physicians or certainly at the resident level are not eager to seek help on our own. So I think as whether it's McCall's being in program director role or any of us in leadership roles, identifying those risk factors and encouraging them to seek help, whether it's starting initially with the program director and support within the department. And if that doesn't seem to be effective, then certainly helping guide them to professional resources to kind of discuss in more detail what may be contributing to their perceived lack of ability to find happiness in anything. Dr. Hogan, would you like to weigh in on that? No, I agree with everything that's been stated. In those scenarios, I approach our administrative chiefs occasionally. We have a large program like all of us do and we have 44 residents. And so I will actually reach out to the admin chiefs. If it's a resident, I don't know as well per se, or they've kind of gone into the abyss of residency, which I really believe is the end of second year into the end of their third year and say, hey, what's going on? Does anyone interact with them regularly? And if it is recognized that they've kind of gone into the shell, I actually will bring them in. I'll go to our coordinators and say, hey, I wanna bring them in, have a discussion outside of their normal mid-year or end of year evaluation period, and just chat with them. And sometimes I'll even do it outside of the hospital pre-COVID or just have a phone call randomly set up. I will definitely tell them you're not in trouble, nothing happened, you didn't get written up. I just wanted to reach out and see how you're doing and those check-ins. And I've definitely pulled the trigger and said, hey, just want you to go to, we call it RFAP, the Resident Fellow Assistance Program. Just want you to go talk to them. And only have to go once, completely confidential. They'll never go outside this room or discussions and anything they discuss with them also being confidential. And that initial assessment, really just to make sure they're well enough and there are no other concerns from a professional that they may not be a harm to themselves, to others. And is there an opportunity for us to really help and engage them? And I will do that. Fortunately, I've not had to do it that many times for the scenario that you presented, but I will do that because that resource is there for a reason. And so I can go from there. Great, so one last question to either of you. How do you handle a patient or a family that had a subpar outcome through no necessarily a mistake of your own, but the just outcome wasn't what they expected? They're unhappy, they're disappointed, which obviously reflects poorly on you and you're feeling bad about it, but you didn't really do anything wrong. How do you approach that family with that patient? How do you move forward with that scenario? McCall, do you want to go first? Yeah, I really try to over-communicate. I have a position in my clinic, my PA and my nursing staff will also, and the MAs will say, no patient will ever leave even if they're unhappy with their outcome. And so I really try to talk to them and say, hey, this is the hand we've been dealt. I'm unfortunate it's happened with them. And I do my best to meet it directly. Again, it is definitely something that it's case by case and some kind of cut to the core more than others. I mean, no pun intended. And I really just try to talk through it. It's easier in some realms with elective surgery, obviously with traumas, it's even more challenging. So I always commend our trauma colleagues and what they have to deal with and really take it from there. But communicating, talking to the team, saying, hey, this is kind of part of what we do. There'll be challenging moments. And I always, my last thing I'll say is I will always tell myself it always could be worse. There are very few scenarios to where something could not be worse. And I try to find that to give me enough foundation to kind of propel forward and do my best to make it better, so. Yeah, and I would add to that just that I definitely let the patient and the family know that I'm there with them, that our whole team is there with them, right? They're not alone in this issue that they're facing. I agree completely with McCall's point about the importance of communicating. And whatever form that is, that may be a situation where I would offer my cell phone. I don't routinely give my cell phone to patients, but that may be a situation where I say, if you ever have any questions or concerns or you think of something after you leave, like, please don't hesitate to call me. I mean, I had a patient once with a clavicle fracture that I fixed and there was no problem intraoperatively. And then the patient developed a pneumothorax post-op and was hospitalized and had a chest tube and that was traumatic. And I was in constant communication with that patient and she was very happy after the fact. And so I think just letting them know that you're there with them really goes a long way. Great. Well, we have hit the golden hour. Thank you so much for sharing your insights and everyone, thanks for joining us tonight. Have a great evening and happy holidays all. Great, thank you so much. Great time. Take care. Stay safe.

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