 I'm really grateful to be here and grateful to be in this role. If any of you are wondering what the newest faculty member, what business he has telling us all about being well, I've asked myself the same question. So I'm really excited. Every department now has been asked to have a wellness champion or representative to disseminate these resources and tools and just to make it at a department level focus. So anyway, I think we have tons of resources already here at the brand. We have a wonderful culture that we're building upon. But I think this is great to just increase awareness and just talk about this more often, not only amongst ourselves, but especially amongst our teams. I think this just makes everything better, the patient satisfaction, physician satisfaction, team cooperation. So let me see if I can get this one more time here. Give it a rest. I just want to make a comment. A cousin of mine is actually a psychiatrist in town. He used to say the worst thing you could ever say to somebody who was depressed and I think you could translate also to burnout is to buck up. I thought that was really fascinating. He said that that would be just demoralizing. Interestingly, Tom Oding at the recent AUPO meeting, who's the program director, residency program director in Iowa, he said the first thing that we look at in a resident who is lazy and not performing well is depression. I thought these were just great comments about the way that we talk about each other, the way that we talk about performance and the encouragement we give, sometimes seemingly trying to be helpful telling somebody to buck up and be better or coming down on a resident who may not be performing at the level you would hope for. Yeah, that was the PC. I'm just ticking like a clock. Actually while we're working on that, we'll jump into this though. Let me just ask you a question. What is it about the culture of medicine that stifles wellness? I've got a few of us a little longer to remember. It wasn't that long ago. There was clearly, and it still exists, even though I can remember when it was largely male gender, and it's much more balanced there, but it is, was there was this macho culture that if you're tough, you do, you just buck it up, in that it's a sign of weakness, almost a failing. If you complain, if you admit that you're having difficulty with your problems, if you in any way seek out or reach for help with the rest, it's somehow a sign of failure to view as an individual. And that's certainly the culture that I remember from my period of time in training, and we're probably 40 plus years ago now for me, but I sense that, I'll ask. I mean, isn't that a sense to the residents that there's still that same old mindset about just buck it up if you show any sign that there's difficulty or problems, you're just not cutting, you're just not, you know, I'll use the word, you're not man enough to go ahead and continue along. And that has been incredibly destructive and I think under life, so much of the difficulty in talking to people that is not smart. That's a stupid approach to this overall, but it's a sad thing to pay your price. And we have for a long time, if you look at numbers, we're as a profession involved and very satisfied, but our marital discord and divorce rates have been way off the scale, our suicide rates have been extremely high, and there's been a huge personal price that has occurred from that type of culture and mindset. And it's time for that to change. It's time for us to commit. We don't buy over that. You're a very nice citizen. We don't accept the test for the grant rate that we are very concerned about the workload balance and we want people to understand that we consider that. I remember they had a Johns Hopkins once mentioning to a resident, he talked about the fact that he wasn't going to get a chance to see his kids. If you're seeing his kids, you're not being a good resident. That's just blatant and wrong. And I think we need to understand that and appreciate it. And I want everyone here to know that I know you feel a lot of pressure and that I for one, as a head of your, that is wrong. That is incorrect. That is self-defeating. And it has caused an incredible amount of turmoil. And we have to move beyond that. Dr. Telford. We all mean well, but sometimes we forget. We're scientists. I'm talking about us in medicine. We're used to diagnosing problems. Analyze it. So a few comments came up to me as I was listening to this. One of my very clever residents told me the other day. She said we had compulsory lectures on burn-up in the 10-3 or the recently. She said, do you think of us that 45 minutes since you were making it compulsory before we start the day to go to the gym or go for a run and feel a lot better? Never was a sure word said. This morning, I had a meeting at 7.30 with the public committee. This was the end of the clock. We were busy there in clinic. Last six hours, you wanted to give me a lecture. I told them I'm busy. They said, why don't you come and give it at 6 o'clock? This disease has spread to the point where we're just assuming that you and I as employees of the university will just excel that day from five in the morning. We're going to Waving Grazie. Waving Grazie is one of our wonderful administrators. He said to me, he comes into the hospital at 6.30, at three in the morning. I remember when we used to work at the morgue here, he and I would have a cup of tea together, have a barbeque, it was a decent start. So I think we need to start diagnosing this and recognizing that we can't just keep on imposing upon people's time. Before residents, we have to teach them after we finish a busy day in clinic or in surgery and we have to start diagnosing cases at 7, 8, 9 at night. There may not be a solution. What I'm trying to give you is the diagnosis has to come first. I'll tell you what another resident of mine said. The last two meetings you went to, they were told the solution was do more yoga and read more books. They've missed the diagnosis, they've missed the underlying causes. So my suggestion to administration, I mean to inverted commas, is listen to what people who lived a life in different parts of medicine, perhaps different parts of the world have to say about observations. Don't threaten them with expulsion. Don't threaten them with losing jobs. Just listen to us. So I put an editorial together last night after I spoke with Dr Olson, which I'm submitting for JAMA, which analyzes all of these things that I've heard from residents. In the last week, I had dinner with about 25 different physicians and all of what they said. Many of these things, they're afraid to say public or in meetings like this, because of fear of attribution. So get to the diagnosis first, is my suggestion. Move on. When we were building this new building, one of the things I suggested was maybe we should have a gym. We work such long hours, we never get a chance to go anywhere. Just rush home, have a shower, go to bed. Most places in the Silicon Valley, they have a gym, they have a bar, tell me, how come a bar, they have a bar. You can have a break. They're by now break. I looked it up. It's 80%. It's a high-fresher place, Silicon Valley. Simple things like a gym in a hospital where staff can use. And I'm just a pointer that our technicians are not here. We have this silly thing called excellent patient experience, and I call it silly, because for a few years I've been telling that we should have two parallel lines. Excellent patient experience and excellent employee experience. Not physician, not doctor, but development upgrade amongst technicians is higher than amongst physicians. You should listen to your law and law statistic. The number of times a technician at the Moran Eye Center is talked down to to the point where they almost feel like weeping is on average once a week. I took an informal survey about a year ago with all my technicians and this is the whole week they're spending all their techniques, not just my credit. Once a week they're talked down to by patients and I ask them, who do you go to and what do you say about them? They have nowhere to go. Excellent employee experience should go on parallel with excellent patient experience. So I'll just point to a few diagnostic criteria here. The residents always laugh at me when I say to them, I wish there was a gym in the hospital and I could just go to it and try to drive through traffic and get to some place where the gym is closed anyway. These are simple ideas but they all count. It's a number of great points. We actually try to get a gym in here. I want people to know it. You're talking to somebody who very much believes in physical fitness is a way to relieve stress I just want people to know that people need to speak honestly about this and I think we need to drill down and yeah, there needs to be a change. So I'm committed ever since Griffin and I were at the AUPO meeting and went over these national statistics and the rest. I think it's a time for us to significantly change and we're all going to be better for it. I agree. We'll touch on all of these points that have been made. I think I love Michael J. Fox. I just think this is our view of the future looking bright and I think this touches on what you were mentioning of what is a big impairment in the culture of medicine and in a lot of our lives. You feel like you're too busy to be well which is so ironic, right? I don't have time to be happy and take care of myself and then in turn probably improve my productivity and ironically I think these are all short-term decisions we make like in a single day I don't have time to exercise in today and that's that and we look at these as all short-term decisions but long-term those are really unsustainable patterns and so let me jump to the survey because I think this is an interesting result but it kind of shows that the president is even bright at the Moran but we did the survey a year and a half ago and they repeated it recently because there was really poor participation the first time around only 16 and this time we got about 32 out of 50 providers filling it out so the satisfaction rates were actually really quite good and overall this our performance was actually much higher than most departments across the university I think maybe the highest this question when we did the survey a year and a half ago maybe it was a bad time like a rainy day or something because we about out of the 16 participants half of them said they were definitely burned out that middle column or worse and this time we got 90% people were pointing that they're not burned out or have manageable symptoms of burnout so unfortunately as I repeat the survey no initiative that we're going to do is going to look better than this which is probably not going to be able to measure this improvement because this is pretty good but I would say even the 10% that they do have symptoms of burnout is not insignificant and I think any day our own answers to these questions would probably vary another thing that's encouraging is I feel like we have strong leadership here and the survey supported that and so there's a lot to build on going forward and healthcare teams as we've talked about a number of times today can't be emphasized enough I think all of our attitudes are contagious both directions you know burnout among staff affects patient satisfaction and the overall feeling of the clinic and that it certainly works the other way too I thought this was a really interesting question and the answers were all over the board about the amount of stress you feel because of your job I'm reminded of the Yerks Datsun Law which is the stress performance curve so I think it's kind of a loaded question to ask if you feel stress at work because to some degree stress or pressure as you can see in this graph is an old, old curve from like the early 1900s actually increases performance because we do better with a little bit of a push but there's this there's this point where you start actually having a fall off of performance as pressure and stress increases and that's where we need to be careful not to get into and the question is are those external or internal pressures that pushes over the edge EMR this is just a fascinating question about who's doing EMR at home you see and this is just the number of participants on the left so 12 people say that there's almost none and then the other about 20 spread out across being modest to excessive mostly being moderately high and EMR time at home is all unfunded so this is a huge contribution to lack of wellness I thought this was kind of fitting at least the sufficiency of time for documentation again mostly felt like it's marginal the atmosphere we work in again this may be a race that stress slide about I think if you're calm or somewhat calm you're probably on your administrative day because most clinics are busy but we probably want to be in the busy but reasonable if you have comments too please shout out if any of these questions we'll have a little more discussion here but another question on the survey was control over workload which a lot of studies say it's the number one factor related to wellness is the sense that people have control and autonomy over their schedule and that was kind of all over the board but mostly good here and again another EMR question the irony of this one is that nobody strongly disagreed that the EMR adds to frustration of their day there you go again so this is just who participated in the survey at the Moran a lot of our senior partners were contributed as you can see so we won't read through all these but I just wanted to highlight the comments that were made at the survey so you see how many times EMR comes up in red as a big contributor to the lack of wellness and then the other thing is tech front desk staffs was the second most commonly mentioned thing so I think the conclusion of the survey is that we actually are doing well there's a strong foundation to move forward with and overall good morale good leadership but certainly a lot we need to do with clinics and EMR and those sort of things we're going to try to incorporate into wellness it's a disservice to talk about wellness and say we're not going to make any administrative or structural changes because it feels like we're just trying to give out ways to cope with the situation but EMR for instance is not going away and so there's certain things that we do have to learn to just work within a way that's more positive and healthy so a couple of questions I love this quote here all that pushing through you do has its benefits to the world I'm not sure what those benefits are to you so we already asked this other first question are there any other thoughts about what is it about medicine or academic medicine that stifles wellness at the same time you know you can't extend I don't think anybody would want to extend training 150% or 51 more years 2 more years to have it more luxurious kind of French take on training and more time for you know going to the gym and reading books and writing poems and such so I think there's a balance I mean I think training has to be intense for rewire skill and takes the number of hours to do that so I mean it's the principle of seasons right at some point you have to say what season am I in and what is a reasonable balance for the season and it's changes throughout every stage of life having that said you always develop habits and I think a lot of people would agree after I mean I'm only my first year but I'm surprised how little has changed in terms of my busyness out of residency I just like things are quite busy and so habits form and so I think there's it's nice I totally agree but we can't neglect wellness during stages of life just under the sake of this is a necessary evil for the season I'm in I remember during my fellowship they said no vacation allowed during our fellowship because we just feel like you need all the time here to to get as much out of the experience but I realized what they meant was we can't actually function our clinic without you present so we need to hear every day but I got a root canal during my fellowship and got a half day of clinic off and I sat down to get this root canal I was in heaven lying down just peacefully being drilled on and we were thinking I'm probably out of balance here to be enjoying this so much that was a sign to me that things were maybe not great so another question who applies these pressures on us to always be getting more of our time always you know is that internal external both what would you say I totally agree and I think medicine I'm the first to admit that I've got my own neurotic tendencies to push we're all super competitive and we all have a tendency to compare us as well right and success in medicine is measured by comparison O caps is a percentile of how you do against your colleagues and so forth and so forth but there's a point where that becomes really unhealthy as well doctor tell sorry instead of just saying where does the pressure come from may I suggest to all of us the next time somebody says to do something in a stupid hour which happens to me on a weekly basis you do what I say which is who's going to hug my kids and when am I going to have a shower and some breakfast so the next time they ask me for a six o'clock meeting I suggest we all say that to our administrators to our bosses to whoever I think they should be a decent French I know Americans don't like the French but the French stopped all emails after five o'clock in business you're not allowed to send an email to me as your employee after five o'clock weekdays and after 5.30 on Friday if you do you'll get a fine the point is they're preserving their own private time that may be a bit extreme for aggressive captains America we should take lessons from other countries and learn to say no and please ask in public not to be reminspected for it it doesn't mean you're not a team player for residents as to me I can't meet you at 7 o'clock after you've done the surgery I'm not going to say you're not a team player I understand what things to do on the other hand I had a medical student say can I leave your surgery at 4 o'clock because I've got a date with my wife the answer is no you can't it's part of medicine so learn to say no can't just say is it internal or external it is everywhere and we need to learn to defend the time I would love it if we said business emails other than emergencies should not be acted upon after say 6 p.m let's do it as an organization interesting that was mentioned again the APO where they had a big section on wellness and one of the chairs said to change the culture at that institution that emails are only sent during business hours and I thought that was I think that's a wonderful idea you can send them at 3 in the morning I'm talking about expecting responses fair, fair I'll say you sent it to me on Sunday of course that money didn't reply well I think this last question here is what boundaries do we draw to maintain or restore balance because I think that's a big principle of wellness do you have thoughts or things that they've done to try to establish boundaries in their own life that have been healthy and helped them feel a little more balanced or been able to step away from work any thoughts I have a very simple one and it took me a long time to do it and as a lot of you know especially the fellows while they were being credentialed I answered 24-7 almost on my phone and it got to a point where I was feeling burned out about it I wasn't feeling that it was being appreciated it was from the fellows but not the whole building and I thought it's stressing me out and I'm not as productive because I'm feeding irritable so I took the notification off my mail because I would look at it and there was even a number one there on the mail I answered it now I've taken it off and it has felt a lot less stressed by that simple thing I can deal with it when I get to work through emergency the residents and fellows have my phone number and they'll call me but as far as the email I don't answer it after hours anymore it's a great comment and I thank you the world still spun around before email existed Bob I think that once you're beyond training, medical training is rigorous, is stress inducing and I think it needs to be to get the job done in your life but that's appropriate when you're trying to build a practice it can be stressful but when you've got a family I think carving out time to do things what I did when my kids were home was we blocked out all their school vacations and did something as a family except for the summer break I couldn't figure that out we did something and different than the situation now that was before the days of cell phones and when we left now no one ever called or contacted me and it was wonderful cell phones ruined that it's pretty much forever I have been awakened at 3 a.m. in Kathmandu because it's 3 p.m. here and someone thought it was a good time to call those conversations are usually very brief but I'm going to take some time out and I think that the idea of finding time whatever your schedule is to do something physical and to try to do some meditation or yoga is important as far as trying to find some balance ultimately you have to find some balance in your life or you're going to burn out so I think the answer is not the same for everybody but back to the training thing there's no way around the fact that it's rigorous and that there's a time in your life to focus on that do the best you can to get through everything else and ask for help if things are going off the deep end I agree I'm going back to that season principle and yet quantity of time at work doesn't always correlate to burnout sometimes it's the quality and the culture in which you work that makes a big difference in how you feel the other part of this is the employees in contrast our schedule we set our own schedules and we essentially do to ourselves as a faculty what happens to us but nurses last example do our schedule for a certain period of time and then they're kept over doing their charity day in and day out I think the burnout rate is very high where it's an institutional thing it's a little different than what the faculty does to themselves by allowing clinics to be scheduled a certain way so many surgeries to be scheduled you know my schedule is my own fault no one else's fault and I take responsibility for that but I do feel badly for those who are under institutional pressure to stay long and be part of the culture and I think that that is one thing that needs to be paid attention to in terms of the employees totally true Norm Amy will come here and then we'll conclude so I certainly agree with everything that's been said one thing I would add medicine about things that add to wellness medicine is an important science and sometimes things don't go well with your patients and that can occur so I think it's important to sometimes be willing to talk about that if you need to talk to another colleague I mean no one is immune for that so you could pick out and send this in this room and we've all had more than one so there's lots of peer support to hash that out you know I'm on this well Coma has lots of that you know we have this Iowa Fellows group of all of us old fellows we have this email service half of it is just kind of just giving each other support or maybe we'll leave what happened I love that comment I think that's what we're going to hopefully use these in-house coaches for too because sometimes you don't want to talk to your peers but I know the worst thing you can do in those situations is isolate yourself there's a culture I'm not talking about interestingly I was on a plane to A-pose and a pediatric ophthalmologist from a surrounding state said to me oh you work at the Moran I had this conversation with Norm I did a complication that occurred from a surgery I did and I was just panicked and I called Norm and he said first of all let me tell you how sorry I am that this happened I've seen this happen before and I'm sure you're just devastated about it and she said that was number one one of the most healing things about it so it's interesting that you said that Norm Amy and then we'll go end very quickly I think that when we talk about self-care and de-stress we often think that it has to take a lot of time and everybody's panicking about it and you get a little bit of vacation or you need to take a half day of clinic off some of these things can be about carving out like Dr. Hoffman said carving out time and space to do the routines of things that you already have to do we all have to use the restroom at some point during the day we all have to wash our hands before we examine patients and you can make some of those times and some of those things your own so start with one minute a day start with 60 seconds it has a great benefit on the other side and some of the 15 minute de-stress group that Lisa talked about we can explore some ways of doing that so we don't have to think big right now if we can start very small Janine I've had some very deep and meaningful discussions with the residents usually unfortunately late in the evenings after clinics and surgeries are over but they don't carry any power I can't power and fire so they speak very freely and I've learned a lot from what they say none of the residents have spoken up today we were 75 years of burnout amongst residents we should encourage them to speak freely and discuss with us maybe informally that's what I've learned a lot what they feel what they think will be done differently and I've said to them don't allow when we have these meetings they become very coy they're afraid to stick their neck out that's that spirit that Dr Olson was talking about you know taking over the field don't complain and God knows I saw that in my early years of the year in my publishing so important for us to encourage the residents to speak to us informally and not pull their feet to the fire creating a safe environment where things could stay we'll go to the last comment and then we need to go I don't want to take a lot of time here but you know one of the things that occurred to me historically we've been able to put ourselves in medicine it's not just action from being in medicine and being in the private community and trying to be in that environment it's difficult it's a little bit different in academics in a way that a lot of the times bigger academic organizations are run by doctors and understand some of the pressures that we experience as doctors a lot of times managed care organizations a lot of us are shifting towards we have administrative sort of businessmen and they don't get us, they don't understand it even my own spouse doesn't get what I have to go and we have to care on a day to day basis and in a sense in my experience we have been approached as we're expendable we're irreplaceable and we can just be changed out it doesn't matter you know they treat us in such a way that it doesn't really, it doesn't matter the lack of appreciation for us is really difficult to care I think that as we some of us in this room especially in the presence of me training on to the more non-academic more private world it's one of those things that medicine is changing and as we've integrated CEOs and businessmen into medicine I think it's littered up and they're really kind of understanding and control the burnout and I wonder a little bit if someone that burnout is coming from that I've been out on this seven years now and a lot of them are experiencing the same things that I'm experiencing too so it's just an important point to always make an advocate I think we'll end there because I don't want to keep it in one