 Thank you for joining us in person and on zoom. I'm sorry for the technical difficulties. We're excited to have everyone here. And I'm just going to take a second to introduce start for gold. We had a meeting earlier with the wellness leaders. That was great. And I'm looking forward to having ethics fellows here and some other faculty. So let me just tell you about Dr. Gold first and then we'll get her started with her slides. Dr. Gold is an assistant professor and the director for wellness and engagement and outreach in the Department of Psychiatry at Washington University School of Medicine in St. Louis. She's a nationally recognized expert on healthcare worker mental health and burnout particularly during the pandemic. College mental health using social media and media for mental health advocacy and the overlap between population between pop culture and mental health, including celebrity self disclosure. I'm looking forward to hear more about that. Dr. Gold is a graduate of the University of Pennsylvania with the B8 and MS in anthropology and the Yale School of Medicine and completed her residency training in adult psychiatry at Stanford University where she served as chief resident. She also writes for the popular press and has been featured in among others in New York Times, the Atlantic, the Washington Post time in style forms and self. Dr. Gold is actively working on a book about healthcare worker mental health and burnout during the pandemic for Simon element, and is a member of the expert advisory council for the Viacom CBS mental health storytelling initiative. She's also the co author of the mental health media guide. So let me go ahead and share her slides. So the people on zoom can see get her started. And then, let me see. Make sure that they have video. It's mute. The audio settings. Yeah. And it doesn't necessarily mean that I'm making light of it. I just think it's a hard topic to talk about sometimes and putting in the other stuff matters. Additionally, as I mentioned to people this morning. Sometimes when I talk about mental health and wellness especially in medicine people get mad, and you're allowed to get mad I get why you're mad. It's a hard topic. Nobody likes to be in a system that's inherently broken and have someone like me come talk about being well within it so you're allowed to get mad at me. This is sort of how I feel I hope this video works. I'm this is all of my disclosures which is a Taylor Swift song. So, I'm going to start by talking about COVID mental health, particularly women move on to talk about the culture of medicine because it's something I think about a lot in part coming from an anthropology background but just kind of in general, and then try to talk a bit about individual strategies within a broken system to deal with your own mental health. So if this works, which maybe it doesn't maybe it doesn't. I just wanted to kind of get a pulse of the room, which is like, are you actively burnt out right now. Maybe also you used to be but you aren't anymore who knows if this is going to work it should work. But you know, I'll give you like just a little bit to do it if it doesn't start working I'll just assume the answer doesn't appear then you do it. Yeah, you have to text this to join and then you put a BRC or you can go on this like link and pull everywhere sorry I should have said that. Part of the reason I even start talks with asking about how you're doing is we're really really really bad at that. And we don't ask ourselves like ever how we're doing and so I like to center the conversations on us in some capacity, did it not work. It should work on here but I don't know. I could give up. Did it go through for you guys to text. Because it's not active that's live. So we're ignoring that so I'm just going to assume that a lot of you are burnt out cool. The point was to actually prove that but pull everywhere is very finicky, and it's definitely open but you know that being said, the reason I'll start with data is sort of to ground you in the fact that you're not alone in this experience. What is the term burnout all the time, mostly wrong. Okay, so when they're talking about it from like a research perspective, or you're seeing it in studies with data, what they mean is this like three prong definition of burnout. The first one is feeling emotionally exhausted. To me that looks a lot like physical exhaustion in people. The second one is depersonalization or cynicism is often used there so like in people who see patients that could be like going through the motions and not feeling connected. People who work in offices that could mean not feeling connected to your work in any capacity, including the people you work with. And the last one is a sense of reduced personal accomplishment. In my practice which wasn't mentioned I see healthcare workers I see faculty staff in their college age kids. What I notice a lot about burnout is people tend not to present until the last one which is a sense of reduced personal accomplishment, meaning that in the beginning when you're emotionally exhausted you're sort of like well I work hard. In America, I'm in medicine, I should work hard. And so that is really easily passed over as a symptom. The second one like feeling depersonalization or cynicism, I think people just kind of think they're having an off day. But the time that it gets to like actually affecting work actually being a reason why you're not doing your work that's when we care because, oh no someone else might notice right. And so that's when burnout, I see a lot in my work. I also like this definition of burnout because I think it tangibly makes sense which is like this mismatch between what you think work is going to be like and what work actually is. So in medicine a lot of people go into it because they want to help people, right. And then when you're actually practicing medicine you're just doing a lot of paperwork, and I don't think a lot of people get meaning from paperwork maybe somebody does but I don't. And so that mismatch between like what you think work is going to be like and what work actually is is a huge source of burnout. And what we see in kind of across the board in studies in this is it's about 50% in healthcare. When you look at the gender gap. There is one, which I will point out. This is just a study of clinicians kind of looking at differences in ages, etc. Women in the study were basically 2.2 times as likely to be burnt out. They were also more likely to report job stress trouble with caregiving impacting work and feeling less valued and heard by leadership. You can see also, interestingly, in this group the 55 and older women are the ones with the biggest gap and the most significant gap. You could wonder if I'm sure someone will at some point talk to you about pipeline, or a resume already did. You could wonder if like once you get to a particular point in your career if you're less supported feeling less valued that that might lead to more burnout. A couple of reasons why that gap exists and like existed long before COVID let me just say the first one is work hours and lack of control over work right so if you look at the data. This is a in comparing women to men a binary gender kind of study but for every five hours that people that women worked over 40 hours their odds of burnout increased by 12 to 15% like that's super significant. One of that you can see across studies that women have more time pressure at work and often will spend more time with patients, but in this same study they also saw that people who are primary care doctors and women versus primary care doctors and men the primary care doctors that were women had more female patients, more people with psychosocial problems harder to do in a tiny amount of time and more people that they said made them frustrated. And so that will also need to burn out. Another thing that you'll see is that women spend more time on the electronic health record across the board but also after hours, and that's a big source of burnout in general but let alone like for women specifically. Then all of the things you'll talk about in this series to me impact burnout you'll see across the board that they do in studies that actually asked these questions but a lot of them don't but harassment, not making the same amount of money, feeling like you're not getting promoted is related to value, and anything else you probably discuss in this series I think is very much related to what you see in burnout and women. And then comes COVID right so I am a big like we didn't magically have mental health problems in our fields because of COVID, but what COVID did was compound all of them. We had new stressors, new things that were causing problems, and that is making our mental health worse. I like this image. It's kind of about PTSD and all sort of trauma related to tragedy overall like what does it like to have a big trauma in a culture, and you'll see that like the medical footprint is smaller than the psychological footprint. I think that makes sense, but we spend all of our time talking about the medical footprint of COVID right. And so if you think about how much we talk about the medical footprint it's kind of like that big foot. But also is that big foot and how much it's impacted the medical system and people working within it right just the medical side. So obviously that psychological footprint is going to be huge of COVID we just haven't really talked about that enough. The studies that have started to come out about burnout specifically and mental health and health care workers are slow to come in part because the people who are doing the research are the people who are actively burnt out. If you look at those studies so this is a good one by a group that has basically studied a group of health care workers over time and can tell you what it's been like over time. Emotional exhaustion and depersonalization higher in 2021 than even in 2020 2017 2014 2011 right so that basically means for some reason our burnout still quite high. And they say oh well the pandemic was worse in 2020 interestingly in their data, like the 2020 part was a little bit of even less burnout perhaps because people were focusing on helping other people had not at all focusing on themselves and there was a bit of adrenaline when they did that, but you can see almost 63% of people had at least one of those three criteria burnout that means that all of us are struggling that's how I take that satisfaction with work life integration also declined. And you're looking at burnout in women versus men again you're seeing that sort of like around two difference in women versus men and still a lot of it's all overwhelmingly work related. This study is interesting, because they looked at physician parents so men who have kids that are physicians women who have kids that are physicians, and they said like what's the pandemic been like for you right. And in this study they found that the women physicians were more likely to have reported loss of childcare to be the primary provider of childcare schooling to be the one performing the majority of household tasks to be working from home and to have reduced work hours. What that means is that kind of across the board women are having these other impacts of being female in the pandemic. I often tell people that like, we're not just physicians, we have all the same stressors that everyone's been having in the pandemic like having to teach your kids from home, and then they added, we still go to work and have to be exposed to coven deal with people who are dying etc right so like that's an extra part of what physician women deal with, but they still have all that same burden and stressors that the whole population's experiencing, which is making the whole population more burnt out in particular women. When they looked at what this did to depression. You'll notice that over the pandemic there's actually a difference between the male and female physicians in terms of what depressive symptoms they're experiencing and the fact that they're experiencing any, and that difference didn't exist before coven. That doesn't mean we didn't have depression before coven because you can look across the board and studies of physicians and we certainly did, but what it means is something about coven is making that gender gap worse, at least for depression, at least in this study. I see depression, often as sort of like what happens after burnout. Yes, people can have burnout and depression at the same time, but oftentimes burnout is a risk factor for depression. If we were to talk about all of those things being new stressors of burnout, it would make sense that we would have more depression. And then there's all this other stuff, right, so coven's one thing, but it's not the only thing, because the world keeps giving us more things, right, so this is about reproductive health access. I'm from St. Louis, you're going to get all of our patients right so that's a big thing that's not not a stressor for healthcare workers in part there's a moral injury component to it, not being able to do what you want to do and think is the best for the healthcare of patients, but there's also just volume that's there and acuity that's there so that changes the workplace. I like this tweet by a therapist because I also just think it describes being a physician in general right now or honestly like a person in general right now. But like the fact that trying to help people in this environment where things are so hard feels like you're trying to hand out sunscreen to people who are on fire right so you're doing the best you can. There's definitely so much you can do and I think that leads to more burnout and like feelings of in in efficacy, and not like you're doing your job as well as you could. When we think about burnout, the reasons that we care about it are not just that it affects the person, I'd love to say that should be the only reason we care, but we're in a system that likes to think about systems right so we need to think about like, okay so burnout affects the individual person in that it leads to more mental health outcomes actually more car crashes, things like that right higher rates of suicidal thoughts. But if you look at what we're actually then doing in our job burnout affects patient care significantly that's why we need to be talking about it patients have more errors patients stay in the hospital longer. And longer recovery times, they report lower quality care so it matters across these measures that we care about in patient care and that we already are following, because burnout has a huge impact on that. And then if you step out even further right, it has a huge role in like what people stay at their job right so if you're staying until you're pretty burnt out and have reduced productivity, you're kind of hanging out in your job not doing as well of a job, and that means that that's harder on everybody else, but then you'll ultimately will leave because a lot of data shows that burnout leads to people leaving their jobs. When you leave patients no longer have access to you and so that messes up patient access, but training a new person hiring a new person, getting a new person in that job costs money. So it's a lot of money to the health system to have people burning out and not supporting their wellness. Despite that, we are horrible at actually getting help. And I think this is really important, because we talked a bit today earlier about the difference between sort of like prevention and intervention. Either way, you kind of cut it, we don't like to get help when we need it so when we're in the point of intervention, we are often quite sick and someone has pointed it out to us. So it makes a lot harder to say like, hey, maybe we should intervene in this earlier. And this study is just a poll through Kaiser and through the Washington Post. But what you can see is we have a lot of people who are impacted by the pandemic we like physical symptoms of all things in healthcare which I think is interesting, probably the main complaints for me are sleep and concentration not at all actual worry or actual sadness. But you can see only 13% of people said they got help, and then this group of like 20% said hey, I needed help but I didn't get it. And why did they say that. So I think those fall into sort of two categories. The first category is systemic reasons, meaning like they can't afford it, they can't get off work. They have really hard hours and it's really hard to fit in going to a therapist or going to a psychiatrist right. That all makes sense. I think that's something that the system has to figure out the solution to to help people get help when they need it. On top of that though, we have this afraid or embarrassed to seek care bit right 17% of people said they didn't get help because they're scared of what that means. And that's something that as a group we actually can change and can work on together. I think we spend a lot of time thinking about how out of our control, the mental health problem and health care is, and there is a lot out of our control I can't magically change your hours. But I can change how we talk about this stuff and how it feels to need help when you get it, and how you might actually feel supported in doing that right. So let's talk a bit about medical culture and why people aren't getting help when they need it. This is a silly cartoon that I warned you was coming. So I really like this piece, it came out right around the time Simone Biles said that she wouldn't be competing in the Olympics. And I think it's important because it really talks about how medical culture is very similar to elite athletics and what it's sort of telling people. It's a good piece it's in the BMJ, but really, you know the part that I really would like to emphasize are the parts that are underlined but what it says is, we are basically chosen as people who don't like failing, and then put in a situation where we compete with people who don't like failing. So then if you feel like you're struggling, that's a failure because you already don't like to be different you're ready or trying to beat people and you're ready where a person who didn't like having any faults to begin with. And then it frames vulnerability as a failure, instead of being something courageous right because we're in this situation where we're told that's not a thing that happens. Then it says a bit later to that because we frame it like that the fall of like a mistake that inevitably will happen because we're human beings is actually a greater fall because we're told it won't happen. Oh no you're awesome you do everything right this is what I do I I'm winning right and then when something happens, it feels much harder because no one prepared you for it, and nobody told you that that was okay. And I think that that is a big part of how we get here which is this concept of self valuation, which is like, if you make a mistake whose fault is that like, do you blame yourself for it, or do you say, people make mistakes what can I learn from that mistake. As physicians, we're 50% higher than workers in other fields to blame ourselves. Right, which means that we say, Well, I could have done something differently, I'm the problem, not. Okay, this happened, it happens how can I learn from this how can I do something better from this etc. In this one study when they adjusted for that self valuation difference, the difference between our burnout and other fields burnout went away. The only thing no it's too simple for that but is it does that mean that that way that we're thinking about stuff actually has a tremendous impact on our burnout yes, and that's again something that we can kind of work on. The problem is though that even if we say okay, so I made a mistake. Let's learn from it, let's deal with it. We have tons of fear about everyone else's role in our life right so I like this study it's a study of med students and sort of the culture of medicine. So if you look at this, a lot of med students say it's basically say it's not a personal weakness to need help, but that other people will think it will be so I'm not going to talk about it. So if you look at the numbers, they're basically afraid of what residency directors will think what supervisors will think what peers will think and what what their patients will think, even if they don't think that themselves. You might think it's totally fine to get help when you need it, but because of all of these external things in medical culture. I'm not going to get help because I'm afraid about all these people will say, or if I get help, I'm just not going to tell anybody, and I'm going to hide it, which you'll see in this data and I think that makes a ton of sense right so it's sort of like medical culture reaches in and changes your mind, even though you have an opinion yourself of what it means to need help right. I just want to point out like, even as a psychiatrist who literally like runs around saying like burnout is normal mental problems are normal whatever that I struggle with this same concept which is like how did medical culture reach into my mind and make me think of things differently. And so I'm a person who says meds are normal getting help with meds is normal. Like that's what we need to be talking about a medicine, but at the same time, I actually had never talked about being on meds publicly despite talking about being in therapy publicly all the time through Twitter, through pieces things like that. And I realized that it was because I harbored a lot of the same thoughts about what other people thought, like I didn't care, I thought being on meds was so normal I didn't even think it was worth talking about, but then I realized I wasn't actually actively talking about it, because of the rest of the things, like what would patients will think that I have the worst mental health if I'm on meds patients will think, I'm not as good as good at my job if I'm on meds, despite the fact that again I told my patients who are healthcare workers over and over and over that that's not true. And so I had to work through that myself so I'm just saying like, this is so normal that even the people like me, like run around trying to say that this is normal struggle with it right and it's okay to struggle with it. We just have to talk about that out loud. And some of that struggle to comes from this issue of like, okay, so I got help now what and like is that really affects my ability to practice medicine. I will say so this is my study. You can anytime there's a QR code it goes to the article or it goes to like the piece I wrote. I will say in this arena, we're doing a lot better. So, according to Americans with Disabilities Act on licensing they're only supposed to ask you, are you actively impaired right now. Impairment is part of it and timeframe matters. You will notice that on certain states they still say sort of like a historical mental health thing or it's just like hey, do you take meds. So that's not impairment, right, if you take meds. So that has dramatically improved since 2017 but it's still not perfect. So the Federation for State Medical Boards has this whole document about things that they would do differently in in licensing applications. This map is based on like how good are those programs and states like following this. The Federation for State Medical Boards doesn't actually have any control. So they can say something and suggest it but they can't make all the states change their like wording, that's a state by state advocacy problem. And so you'll notice that they'll say things like it's either maybe we shouldn't ask the question at all, but only 17 states do that right, or they'll say maybe we should have more supportive language unless stigmatizing language, and only eight places have that right so that's how the Federation a lot of places are doing better with the impairment and the current part, which I think is helpful for people to know, but we still have places to grow with this. And it is a valid concern, I just think it's a lot of lower, more than it is like actual things that happens with you get help, or you want help. I think you should still get help because that's what matters this whole concept for the most part is illegal we just don't fight it. Another thing that happens is we actually have no idea what we need help. You can say to me like but Jesse, we go to med school and they teach me signs and symptoms of depression. Cool, right. Doesn't matter, because when it actually applies to us we're horrible at it. That's why their objective measures but even without that we're just really bad at this so this is one of my favorite studies, small and, but it's surgeons again I every single time I give this talk about it, but it's surgeons Jesse. Yeah, it's surgeons and they have their own culture but at the same point I actually think this relates to everybody we just have a different baseline right. So what they did is they had these surgeons do the male well being index and probably the most common measure for well being in healthcare workers. And they asked the bottom 30% how they thought they did the bottom 30% said 71% of them said I'm average or above average. Which means that someone who's doing horribly can look next to them and say well, like that person sleeps about as much as I do, or that person looks like a little bit more sad than me. But just because we've like normalized not sleeping not eating, not getting help feeling burnt out and feeling sad all the time as a part of culture does not actually mean that that's good. What it does mean is if you're struggling. How do you know if you're struggling, because everyone else seems to be struggling to and so you have this sort of conceptualization that like, hey, maybe it's just medicine, like maybe medicine is a field in which you struggle, and if I'm struggling that's normal, but it's very hard to then say like, okay, when do I get help because everyone else feels like this. And so we have to kind of think about ourselves in the context of this culture to say, it's okay to get help again want to point out that as a person who runs around giving talk some burnout. I also had no idea that I was burnt out. I spent the whole pandemic saying, I am tired, and I have a physical health condition, and my primary care doctor is going to fix it and they need to do labs and I will feel better with whatever they find on labs. I had low B 12. I thought that would be the answer to all things. It was not. I still felt horrible and slept every day after work. And then I would say, but I'm a psychiatrist. I'm not a frontline worker. I'm at home in front of my computer. Therefore, I don't deserve to have any sort of mental health repercussion of what's going on. Very common thing for people who don't actually go into the hospital but for sure for psychiatrist right. Then I had these experiences where I was like the expert in the article, and they're like hey like tell me about burnout whatever and so it's talking about burnout. And I started to talk about how I didn't realize I was burnt out until my therapist told me I was burnt out. And I somehow magically ended up the lead in both of these stories meaning the first paragraph because turns out we don't talk about burnout ourselves that it was such a novel thing that I went from being the expert to the story and turns out like people don't talk about how hard it is to identify. And it's I've now become sort of like the burned out burnout expert, but I'm totally fine being that person and being the person who's like, It's really hard to notice this stuff. And we really don't want to admit that it's coming from stress and strain from work. We really want to just say we're fine it'll go away. And it's not that easy. And honestly what my therapist was like you're a frontline worker who sees frontline workers what the heck else could this be. I was like laughing I was so embarrassed, and I was like I'm burnt out huh, and she's like yes. And she's like why are you laughing and I was like, because I literally just gave a talk on this yesterday. And she was like it's fine like we're really bad at self identification of problems. And so that's in part culture, and it's in part just how we conceptualize ourselves in this whole thing where we're giving to other people and constantly giving to other people at home and at work and focusing on ourselves which is why I asked the sort of how are you that failed miserably at the beginning. So what can we actually do about this right so cool. Thanks Jesse gave me all this really depressing material about how I'm burnt out how you're burnt out how everyone's burnt out and they were before and they'll continue to be so what now right. So, the main thing here is that no matter what the answer is not any of this. So, I am not solving your burnout by giving you a lecture on burnout. That's silly, but sure, I get people who think that I can solve your burnout by just appearing and being a checkbox. They also love to give you free food, nothing wrong with free food, but if free food is the only thing then that's a problem free food in the context of change is important. Plus, I really like this video which who knows if you'll hear it but do it again. Good job. So, the reason I like this video is because I feel like the same thing happens right so someone tells you to go to yoga someone tells you to deep breathe and you're like, that's absolute bullshit for lack of a better word. Right, like you can't tell me that I'm yoga in my way out of this or I'm deep breathing my way out of it. Again, doesn't mean that deep breathing is bad or a bad coping skill, but it means when you're actively having a lot of other issues and there's a lot of other issues in the system. It feels really bad to be told to do that right, and I like this encouragement stone thing too for the same reason which is like, people send me this stuff over DMs on social media all the time because they think it's funny so like people got commemorative coins for working during the pandemic and not money right. So nurses week they gave them stones like what does that even mean, and I will tell you you shouldn't give angry people anything they can throw. Like what's the point of giving nurses stones they can throw it at your car but they can't fix any of their problems right so we have to be like thoughtful about what these gestures and what these conversations mean it doesn't mean we can't have these conversations doesn't mean we can't show appreciation for someone, but you do have to have that conversation appropriately, which is in part this need to focus on all levels right so it's not the individuals problem that they're burnt out. There's tons and tons of data that says physicians are more resilient than most right, and even the most resilient of people have burnout, so it is not about internal resilience, and when we frame it that way, it's problematic. To frame the fact that you could build like stress skills and resilience in the context of a broken system and actually have conversations about the fact that we need systemic change to, then I think it's much easier to stomach, having been told to go do yoga or having been told that these things help your resiliency and you hate that word right. It's so important to conceptualize this. I'm talking in an ethics panel right as an ethical issue right so this is a UK ethics website. They talk about how employers basically have a duty to be ensuring the health and safety and well being of their workforce. So that is part of having an ethical workplace. And I think that's really important because even if you just say hey physicians are the people taking care of patients and then if they're not doing a good job you're actually hurting patients and that's unethical, you could view it from that point, but you also could say, hey, I want my workers to actually be happy and want to be here and provide a place where the values of the institution match up with what they're experiencing, which is important in an ethical conversation to. So how do you do this. So I said we're horrible at noticing signs and symptoms in ourselves. So part of this is actually noticing signs and symptoms in yourself so taking time to do self check ins taking time to ask yourself how you're doing. We don't do this at all. Super important, because what happens is this is again sort of like a PTSD view of symptoms. We come when we're in the red. You can tell me you're you need to take time off work you need to go on disability you need to take vacation. That's what the red is right. You're showing up at a psychiatrist and you're saying fix me give me a med is there a med that cares burnout. And I say no right. And so we need to be able to say like, hey, when do I start experiencing yellow symptoms like what does it look like for me to start being burnt out. What does it look like for me to really know that I need help, because you are the only person who can understand you, right. So you need to be able to understand you in the context of everything again you in the context of medicine. So I'm not going to tell you, you need eight hours of sleep if you can't possibly get eight hours of sleep. But you know what you can do, you know, and I think having yourself in this context matters, so that you can start to notice before you're really really sick that you need help. What you can do that is with objective measures so like some places pay for things like the male well being index and you can track over time see how you're doing relative to other people. There's a lot of apps that you can just track your mood track your feelings really quickly. These two links in my, in my presentation are basically a bunch of psychiatrists ranked apps and like went through and said are these are they actually good what are they doing with your data etc. And it's just like you can look up every mental health app on there and see what works you would also just like Google like top mental health apps for mood tracking and see what you like. But it helps to know things earlier, if you track signs and symptoms. Part of this is again this concept of like, what is burnout in me, and what signs and symptoms that have I been blowing through to wait until I'm having problems with personal accomplishment at work right. I wrote this piece recently for self about these kind of like signs and symptoms we don't tend to recognize so anger being one of them. Changing your schedule so that you're like ordering in more or not going out as much but it's not like you're depressed you just tired and you don't want to do that stuff and sort of noticing these things about ourselves is really again important for me it's for me it's like I hate emails. If someone sends me another email I will throw my computer. If I feel like that I'm burnt out or I'm getting there, because that's an irrational reaction to someone asking me for something. I think that that's just because I can't possibly take on anything else but that reaction is not what it should be. And so noticing that in me is way before I'm at the time where if I need to take a vacation or I can't keep working. It's earlier. Same with patient inbox I have the same feelings there. Again, when are they a problem problem like you absolutely need to go see someone like me or someone who's a therapist in the DSM for all things like mental health right. It says like these other aspects of deciding if something is a mental health condition so not just the symptoms so yes there are symptoms of depression, but in the context of the pandemic, a lot of people have a lot of those symptoms. A lot of people have been having trouble sleeping having trouble concentrating not being as interested in things etc. How do you know if that's actually depression. Well you can ask someone like me, but you also could think a bit about these things for you so when you're tracking symptoms, you don't just have to like kind of know what it feels like for you you can say well am I at the point that it's really impairing my functioning that doesn't just mean at work. So people who work people go to school. We're good at work in school, we can do work in school basically we can be like so depressed we can't get out of bed and our grades are still going to be as because we will find a way to still be an a bad measurement of how you're doing is if it's affecting the thing that you're good at and know how to do like basically on autopilot, but is it affecting your relationships easy place to start you tend to not want to see friends tend to yell at the people closest to you, those sorts of things are good signs that it's affecting your life, even if it's not affecting your work life yet. Frequency and time course so how often is it becoming a problem, is it coming a problem more often now right are they are your symptoms severe worsening you might just start with severe because you're ready blue past everything but once you then get help or to give an occasion or whatever you have to do, you kind of starting back at the yellow right so how do we not get back to the red again. Getting worse, some of this is, can you empower leadership to have a better awareness of what signs and symptoms to look out for in the people that work for them. That doesn't mean saying like hey you, you didn't respond to my email for like two weeks something's wrong with you, because that doesn't help, but opening the conversation and having a conversation about what's going on in a in a better way right across the board to you'll notice. It's not just what can you do yourself. It's what can you do sort of collectively as a team. So supportive work environments are like across the board, the best thing at preventing all things. So in our data at WashU they did like kind of over time data of what people are experiencing in the pandemic. The only thing that made things better was in the people who had supportive supervisors. There's no burnout, less anxiety, less depression, if your supervisor was supportive. What does that mean, literally nothing besides you think they're supportive. So, how does that happen, it's like a conversation, it's a environmental, it's like a feeling. Not for but I talk about feelings in a in a medicine conversation but it's really like what is, what does this feel like for you and do you feel when you go to work every day that you're supported and across the board in these studies like if you perceive the support, you're going to be doing better. Plus, the reverse is true. So not just having a supportive work environment is going to help you that be burnt out burnout itself is contagious. This is a kind of smaller study. It's interesting study and they kind and this was over the pandemic and they're looking at nurses and doctors and burnout and stuff. They're mostly focused on the emotional exhaustion scale. But if you kind of look at very much matches right so they have emotional exhaustion questions about the individual, and then they asked them like what's the climate like where you work are other people exhausted, and it is like, it like pairs up basically completely. This ICC thing is they're looking at the how how strongly the people in the same setting resemble one another and basically for emotional exhaustion it was like 15 to 17% was explained by the work environment. So if you're in a work environment that's burnt out, you're going to feel what they're feeling it trickles down it makes a lot of sense it's like growing up in an anxious household, you learn to process things through an anxiety lens it's very similar. So how do you actually talk about this, probably the number one question I'm asked which is like super bizarre because you think that people know how to do this but this paper that links to is like a whole chart on this that I wrote. But basically, again, not coming at people with what they're doing wrong, coming at people with open ended conversation just like you learn for everything and trying really hard to normalize it so. If I'm having conversations that might be difficult doesn't mean everyone's going to take the bait, but starting more like the pandemic's been really hard for me what's it been like, or this week's been really hard I haven't been sleeping how's it been for you. Yeah, maybe they still think you're their boss and they might not say something but you open the door to those conversations being normal which matters. Try not to problem solve, but actually know where you could problem solve if they want it. Sometimes people will upfront be like, do you want me just to listen, or do you want me to problem solve and that can help you if you're a person who can't problem like can't help the problem solving aspect. But if you're a leader knowing where you actually can send people matters so like having that in the back of your mind, even if they don't ask for it and just say, hey, I know some places that are resources would that be helpful to give to you to without just forcing that on them. Some of that is literally just vulnerability, right, we hate vulnerability, because all things vulnerability uncertainty risk emotional exposure means that like someone can reject you. We don't like to put our feelings out there and have someone reject us, but it actually is super important for like leadership culture for culture in general. It's the school term openness and support but also if someone's vulnerable people see them as courageous and empathetic which are both values and leadership, and it's literally the only way you can be creative. So if you're not open to being wrong, if you're not open to rejection in some capacity, you don't have the ability to try different things because you don't want to fail right. Okay, cool Jesse like you just like being vulnerable because you're a psychiatrist of course you do. But there's data that this matters right so if you look at this is a cool study that just kind of came out over coven where they had people watch these videos of nurses, talking to nurses, getting help, and what it's been like and what the barriers were. And in both interventions meaning either seeing a black or white nurse talking about it. There was an immediate increase in people wanting to get help. And that effect was larger in the people who'd never gotten help before, which means like having these conversations has an impact. It doesn't have a long lasting impact so if you look at kind of ends when they asked at 14 days and when they asked, but in the immediate need. If you talk about it, it can help people get help if you do it correctly so it does matter and it you know they don't have it over to they didn't have them watch the video multiple times or something to so you could also say, does it help to repeat it with someone else, and we'll having these conversations continuously make a big difference. Briefly, then you say okay so like I am a human and I don't know what to do myself to survive in this system that's taking forever to change and I need the system to change. I know that have worked for my patients who all have very similar lives to you guys, but I start at like, we view coping skills, like they're these prescribed things that work for everyone, but we really should view them like copies. So, I don't like mindfulness, is there data that mindfulness works times right does do I tell all my patients it's an option, absolutely, but did it work for me know right so having the ability to not just say well they give me yoga classes so I can do yoga if you hate yoga hate yoga do something else right, these things are very personal, we don't view them like that, but there's no such thing as failing at coping because you don't like mindfulness, and lots of people come to my office and they're like but Dr. World I'm so bad at coping, but that's not a thing, you can find something else that works, sort of like a hobby, and there'll be different and long term and short term things that work for you, and you can write on a piece of paper. So when you're super stressed out and you can't think about anything else, it's on a piece of paper and it tells you what you actually like to do. Importantly to you only need a moment right it's, we have this thought that like, I need 45 minutes to like whip out a yoga mat and do yoga, right. It would be awesome if I had 45 minutes every day to whip out a yoga mat at work, most of the time you don't right, all these things are quick things that people in healthcare do, gelling in and out of the room walking the stairs, taking a brief like one two minute break after meetings, these things really matter in, they don't take forever and you can implement this pretty easily without feeling like I have no no control over my schedule Dr. Gold how am I supposed to do this. Well no one knows what's going on in your head while you're gelling in and out, you can find a way to use that to your advantage. Additionally, we exist in this world where we have to pay attention to social media and we have to pay attention to the media but it also sucks the life out of us. Right, so there are not there's not good news there hasn't been good news, all of coded but we just digest it and we live in a world where our patients are really, you know, bringing this in and so we have to have these conversations, but we also need to make sure that it affects us. So you're allowed to turn it off, you're allowed to simply go turns out I've been grinding my teeth and not sleeping things to social media and going on a rabbit hole. Maybe I should watch that and realize that I don't need all that information and people used to watch news one hour a day and be totally fine, and how do I change my behavior to still be sleeping. So for me I don't use my phone before bed if I can I try to read before bed. I tried to use a real alarm clock for a while because our alarm clocks are our phones for the most part and that didn't really take. So these things that are like not huge changes to just say like I am paying attention, but I don't need to pay attention 24 seven. Additionally, the way to like kind of counter that self valuation thing is to practice self compassion, pretty much none of us are self compassionate because when you're a person who's high achieving it's very easy again to blame yourself for everything and consider yourself pretty horrible until you do something like fantastically and then you always think there's more. There's a climb, no matter what. So having the ability to go like, hey, that wasn't a really nice thing I said to myself, and kind of checking the words that are coming out of your head is really important in these situations so the world's mean enough for patients are a lot enough that there's a lot going on we don't need to add to that by being into ourselves. So like people will say talk to yourself like someone who loves. Sometimes people say talk to yourself like the little version of yourself like the kid version. I think those are helpful. All it means is if you start to catch yourself just saying like I'm stupid I'm useless. I'm not good at whatever, trying to reframe that and just say like, actually I've been trying really hard. It's been a really hard week, whatever it takes for you. I'm not saying you're going to do this every single time I'd love to tell you would do this every single time your brain makes you not self compassionate. But if you can just start doing it like once a week. It'll make a big difference. One of the ways you can do this to is this thing that they started to do called three good things, which is basically they text you before bed two hours before. And you just say like what was a good thing that happened today what did you do what was a feeling that was positive and associated with it and in those studies, the there's improvement and emotional exhaustion based at from baseline depression and happiness, and it sustained, what you were just doing, like 15 days of what what was good about your day made people have like actual sustainable changes and it's not a huge thing again these are like tiny little changes. This it all comes from here, which is this well being toolkit that do cast they also do self compassion they also do sleep. There are these little like bite size they they call them bite size interventions for people who are busy, but they all like come through your time and are huge interventions and really do make a difference in sort of how you're framing things, how you're coping with things, how you're dealing with things. And then of course like asking for help when you need it. I just think we think we have to be very sick to need a therapist or very sick to go to psychiatrist but it'd be really nice if we viewed therapy and medicine like most people in social work training do which is it actually makes us better at our job to understand ourselves, and we should get help earlier, especially as leaders, you know, I think that we think a bit about how like, well, that's me what I do in my home is what I do in my home. You know, modeling, coping and self care and what you do and that you're struggling. That's good leadership. And like getting help in other words is good as leadership. I've talked for a while but I know that there's questions on this computer but is anybody else have questions. I'm here. And standing on my dead plate. Yeah, let me, I will read the two participants raise their hands. So let me see what we have here. Okay. West Coast Academic Health Center requires that there'd be five members between zoom meetings certainly not enough time but encouraging limiting the number of meetings per day would be would be helpful any thoughts about that. There's this concept of sort of like, looking at your schedule with like intention, and, and I don't think we do that very well because we think we just completely don't have control over it, but it's not always true. So if you looked hour by hour at your schedule you might say every Monday I hate Mondays not just because it's Monday, but because all of these meetings are horrible and just really bother me. And so how do I actually get to the point where these meetings aren't all on the same day can any of them move so that Mondays aren't the worst day of the week. Is it possible to give yourself buffer time between zoom meetings like that said to say like I just need five minutes to like center and deal with it and process it whatever. I don't think it's possible to get between patients despite having no time in between patients, get up and walk around my house, get a drink of water, and I'd rather be a minute late than actually being miserable the whole day. So trying to balance that I think matters I don't I don't think we're taught that very well especially like the bite size things. There are definitely things in your day that you get more meaning and purpose out of than other things and paying attention to that to say like, turns out I really like mentoring people but that goes first because no one pays me for it. I include that in my day, because it actually helps me mentally, and that's the benefit of it, not just that they, you know, it's some sort of academic expectation. Just the stigma about wellness and health care. Yeah, I just wanted to ask about the stigma of wellness and health care I think this, this concept of, we don't talk about it. We don't, we don't kind of acknowledge that it's there. Can you just like put your goal here look in the in the future and just see like how do you anticipate that changing. You think it's going to get better quickly do you think it's not going to get better at all like what do you think that. Yes, so the, the answer to this question is like how do we change culture it was going to take a really long time because all culture culture takes a long time but I actually think that the younger generation is much more mental health aware to begin with. And you'll see on social media, like people post when they don't match, like I couldn't do that if my life depended on it when I was in med school like that would have been the worst thing I could ever like I wouldn't even want my classmates to know let alone the whole world. So the fact that there's this culture of like hey, this is a thing that happens, we're all supporting ourselves through this and like this is normal. I think is a big sign of change in sort of the, the up and coming group of people, but the biggest problem I see is that the people who remain in sort of like the older group of people have a opinion of like, we went through it you should go through it to, or those people talk about mental health and complain because all they're doing is complaining and they can't just deal with it. And so I think we need to have conversations where it's like they're not actually complaining they're just more aware of these things that doesn't mean the system is any different from when you went through it, but it does mean that we've changed our view of how we deal with wellness in the workplace. And so we have to have these conversations as opposed to saying like, they don't know what they're talking about. It's like silly little woke, like young people who expect these places to be nice. But I think it's just actually crossing that divide and having like good conversations, instead of both groups hating on the other so the younger people are also like those people are horrible. They don't know what they're doing. I'm never going to become them and so trying to balance that I think is really important and like having good open conversations instead of just like shutting them down. Well, you can go next. How about that. Let's take a question from the room and then we'll go back to the zoom. I will repeat the question. So the question was basically money and wellness and how do those relate and why do we not talk about it more. I think we don't like to talk about money at all ever right so I think culturally, like not just in medicine, people don't like to talk about their salaries don't like to have transparency over things like that. We don't talk about like money is this thing that's just there and we don't talk about it. So I think some of that is just culture not medical culture and money. But I think it's also just like a harder thing that feels more out of people's control right so how much you're paid feels very much dependent on like where you work what you're doing like all these things that feel like not in the realm of being able to be changed as easily. And so I think people kind of tiptoe around that because it's scary to have things that you don't have control over be a big source of burnout. But I do think like, you know, there's some of that in the gender data about compensation being related to burnout, probably not enough in like academic settings versus external settings. I mean, I'm a psychiatrist I mean I could be paid a ton to be in private practice I'm not right. So I think having that awareness I think matters but we don't. I think that people have just shied away from asking money questions flat out because we don't talk about money like it's just, which isn't good. So probably we need to get more comfortable talking about like you know salary transparency is a big thing for gender equity right so being able to apply for a job and know what other people got for that job. And so many Dr Burnett second question kind of relates to that too is like that when we decrease our effort, this is, you know, making your job more sustainable than conflicts with your financial incentives. And so, you know, trying to improve burnout. So you kind of answered this but I'll just go to this first question from Dr Burnett, setting boundaries and decreasing your discretionary effort can be a way to protect against worsening burnout. It also results in less communal work interviewing candidates for residency how would you propose to address that part of it. Okay, it's I would say it's not that's again not a super easy question to answer. I've noticed that the filter by which I do things like what I say no to and what I say yes to needs to include my emotional exhaustion and my feelings. So we tend to, you know, when we're younger we say yes to a lot of things for promotion we say yes to a lot of things what it does to our career, but we don't necessarily go like hey do I actually have the energy for that do I actually have the ability to do that. I like doing this what gives me enough back doing this you know and sort of balancing that I think it's important to like when you're weighing things and saying yes to things and thinking about dropping something that you actually include. I don't like to be doing this in the in the weighing of like sort of risks and benefits of not doing something, because we tend to sort of just think about them as things, not things that are actually affecting us day to day and sort of weighing that is the best I can say to do for that. I wish I could tell you like, you know, I could get you more compensation for discretionary things but I will say women are more likely to drop those things and do other things and so you'll notice like that'll be the first to go and then they'll cut back time and then they'll actually leave the workplace so those just like keeping people in the discretionary efforts that don't have time because of external things is something that like systemically we need to think about too. So, Dr was questions basically about staff wellness and what can we do to to maintain our staff wellness. Yeah, so I primarily have fallen into a role of doing faculty and staff wellness in part because the other stuff was set up so our med school had ahead of wellness they had access to therapists they had all that in place they had groups, maybe it's not perfect and maybe the med students could tell you 100 things that are wrong with it, but it was still there. And then GME right before the pandemic had hired ahead of GME wellness and so they would also started building that. And then it was very clear that if the staff and the faculty weren't happy. It trickles down like the same way as if you work on a team that is burnt out you feel burnt out but if your attendings looks sad and angry all the time, they're not going to mentor you as well. They're going to make you feel like you don't want to be a doctor there. It's going to make it not for sure not make it like you want to stay in that particular system because you saw what happened to the people who stayed in the system. So having this like awareness that that all trickles down is super important and I think the only reason it hasn't been focused on is like GME and you and me put it in there like regulation so you like can't be accredited if you haven't thought about it at all. We don't have that, like to me, it should be a hospital systematic just like patient satisfaction, like do people like working there. Because if it was exposed at like at that level, then people are going to say well that place has a 95% of like people liking working there and that place has a 60, like then the person at 60 is sure going to figure out how to get to 95%. And that's like a big transparency of like what we actually do for wellness versus what we say we do for wellness which I think is a really big problem. So one is like actually being transparent about that at a highest level. I gave a talk for a hospital system that talked about how they talk about wellness and recruitment and how that's built into like packages and ways that they're like recruiting people over other people and like including flexibility in contracts and conversations so I think centering wellness in the recruitment process both even in like the piece that stuff that you're putting out as like a job description, but also in conversations with people. I think shows that it's valued by the organization and matters in our organization, we've basically tried to set up similar access to care for faculty and staff that the residents have so like, yes, you can use the employee access program and go that way but you can also come to us in two weeks and be seen quicker and have support and we're there and I think trying to basically build some of the similar stuff so that especially to if you were used to having it in med school and presidency and it goes away. Then you also lost a big support so having similar stuff set up in that level I think matters and then also in the faculty level realizing that all things have mental health outcomes. Like when you're in a childcare conversation that you that that matters also because people might burn out and leave your institution, or when you're in a financial compensation conversation that you realize that if you don't fix that people will burn out and leave your institution so having that as part of all talks I think matters to in the faculty and staff level. Because we tend to really like seclude those conversations and they're not at all secluded. I don't know if that answers your question perfectly but okay. Yeah, and I think it's a lot of this like transparency and messaging thing we're really bad at so I like health communications right like I do social I do media I write is very important to me what words we use and why we choose to use them. And I think it's really important to people more than people realize so I can't tell you how many people showed up in my office for like a triggering email, because the email was implying that again they were going to be asked to work on coven units. And they were like but I did that. And like I didn't like that and it was really short like I know immediately everyone's like they're going to move me from psychiatry the medicine and it was like this huge reaction, but actually the email was like it was a voluntary and it was a different thing, but their first like gut reaction was like, we're back there this is horrible I can't do this so like having an awareness of like how much communication matters and thinking about that in a thoughtful like mental health triggering sort of way I do think really makes a big difference even from like you know leadership conversations with people on their team and that sort of stuff because we just don't learn that. You don't learn that really ever but you certainly don't learn I miss and like that words matter. I mean it's the same reason I use mental health and wellness, because they're different. Like, wellness is more prevention, and doesn't actually include going to treatment, but we blur it. And so everybody thinks that like if you're talking about wellness you're talking about going to psychiatrist that's not this I don't do wellness I do mental health. So like I think it's having like a awareness of that. These things are spectrum and there's different words and there's ways that we can communicate it better I think does matter to. Oh, do you want to, I might just wrap up the zoom thing and then if you guys have time to move down and we can do your question when you're going to have time with her is that okay. Okay, good. So we will wrap up the session and stop the recording. Renana and then I think those of you who are ethics fellows I'm going to spend a little extra time with her if you want to come down and we'll sit right here as we have done in the past and and talk with Dr gold in more detail. Thank you again for a great talk. Yeah.