 Hello, and welcome to Noon Conference hosted by MRI Online. Noon Conference connects the global radiology community through free, live educational webinars that are accessible for all, and is an opportunity to learn alongside top radiologists from around the world. We encourage you to ask questions and share ideas to help the community learn and grow. Today, we are honored to welcome Dr. Inez Mohamed for a lecture entitled Psychological Safety as an AC-GME Requirement, Challenges and Solutions. Dr. Mohamed completed her residency at the University of Toledo and was an abdominal imaging fellow at the University Hospitals of Cleveland. She's an assistant professor of radiology, division of abdominal imaging at Case Western Reserve University, University Hospitals of Cleveland. She's also the associate program director of the radiology residency. At the end of the lecture, please join Dr. Mohamed in a live Q&A session, which he will address questions you may have on today's topic. Please remember to use the Q&A feature to submit your questions so we can get to as many as we can before our time is up. With that, we're ready to begin today's lecture. Dr. Mohamed, please take it from here. Hi, everyone. My name is Inez Mohamed. I am assistant professor of radiology, abdominal imaging and the associate program director of the residency. Today, we're going to talk about psychological safety as a new AC-GME requirement. I have nothing to disclose. Our objective today is to know what is psychological safety, what are the barriers, discuss the impact of creating a safety culture in healthcare and also to identify methods of fostering psychological safety in the residency program. So what is psychological safety? Psychological safety is a personal belief that one can speak up, take interpersonal risks, express concerns, admit mistakes without the fear of being shamed, blamed or ignored. The aim is to create a culture where everyone feels comfortable admitting their mistakes so that we can learn from our mistakes. We turn our failure into learning opportunities. So next time when we are faced with the same challenge, we are able to take better decisions. As of July 1, 2023, AC-GME has promoted psychological safety to be a requirement all residency programs have to comply. With the AC-GME common program requirement definition, psychological safety is an environment of trust and respect that allows individuals to feel able to ask for help, admit mistakes, raise concerns, suggest ideas and challenge ways of working and the ideas of others on the team, including those in authority without fear of humiliation and the knowledge that mistakes will be handed justly and thoroughly. Now that we know what psychological safety is, we have to stress what psychological safety is not. It's not eliminating personal accountability. It is not a permission to incompetence. It is not a guaranteed applause. If I am saying that I'm going to actively listen to you, that doesn't mean that I have to certainly agree. So psychological safety and accountability should go hand in hand in our residency programs. We don't want high psychological safety without accountability that will place our students in comfort zone. That means complacency. They don't have to do anything. If, of course, we don't want high accountability and low psychological safety, that's an anxiety zone. What we want is place our residents, our medical students in the learning zone where there are high accountability and high psychological safety. It is particularly challenging to foster psychological safety in healthcare. Why? There is built in hierarchy in medicine. We have medical students, junior residents, senior residents, junior attendings, senior attendings, section chiefs and so on. We also have different teams working together. We have nurses, we have admin, we have technicians and among these there is hierarchy. Hierarchy is not built in to be a bad thing. Actually, the most senior person is more knowledgeable and this is put in place as checks and balances to ensure patient safety, to have better patient outcome. The problem, of course, is that it makes picking up or building a safe culture more difficult. Other thing, of course, is lack of awareness. Why do we have to implement psychological safety? Multi-generational workforce. Most of our residents are in the new millennials. Last year, Radiology actually matched the first generation Z. Each generation have their own aspiration, their own way of communication, their own ways that they want to learn through. Other thing, of course, is that in medicine in general, it's challenging and fast-paced environments. Sometimes we have to take a crucial decision within seconds to save patients' lives. It's not really easier in Radiology. A big factor, a pillar for psychological safety is having interpersonal relationship between the education and learner. Radiology now is a hybrid learning environment where people are working remotely. Also, sometimes residents are working with attendings face-to-face in the reading room in the morning and then they go on call and they are dealing with attendings. They have never seen before. Other thing is that we are all under stress from the increasing clinical volume coupled with Radiology's shortage. So why does it matter? Why is it important to actually have psychological safety in our programs? Chernobyl, April 26, 1986. The worst nuclear disaster in history. Hundreds were killed, thousands left with consequences of high radiation exposure, including cancer. The Committee for Safety in Nuclear Installation in their report on this incident for the first time they introduced the term safety culture. It was said that that day in the control room, there were workers who knew that something was wrong with the experiment that they were doing. But they were so afraid, they were so worried that they would be humiliated. They were so afraid that if they spoke up to those in power, they might get fired. Also, it was said that there were two explosions that day. The people who actually managed to escape the first explosion were so occupied with who is going to be blamed for this disaster that they did not tell the people who were living within the vicinity of this nuclear implant of this disaster that they have to run for their lives. The people did not evacuate in this city for 36 hours. Fast forward 2003. Amy Edmondson was a PhD student. She was going from one hospital ward to the other in a pediatric hospital. She was studying the relationship between working in a healthy environment, high trust environment, and mistakes. That's when she found out something that did not make sense to her. She found out something that was controversial. She found out that nurses who work in effective teams who have good relationship, who have good leaders were actually doing more mistakes than nurses who are working in a few culture. When she investigated that further, she found out that, no, they did not do more mistakes. They actually reported more mistakes. And that's when she wrote her 2004 paper Learning from Failure in Healthcare. Dr. Amy Edmondson is the first to introduce the term psychological safety. She is a godmother of psychological safety. If you Google psychological safety right now, you will see her pictures, her talk. You will also see lots of information about the importance of psychological safety in business, in economy, but in fact psychological safety was implemented for medicine. Why? Study after study has proven that there is a direct correlation between patient outcome and healthcare team working in a safety culture. I want you to grab your attention to this particular paper, which I think was very alarming. This paper was published in Annals of Surgery in 2019. Imagine a complex abdominal surgery going on. And there was in the OR, there was a resident, the surgeon who I am quoting here was notorious for explosive triads and flying objects. And there was this invisible medical student who was watching the surgery going from far away. And when he noticed that, the green towel that's supposed to cover the handle where they moved the light was missing. And he also saw the surgeon and the medical student repeatedly reaching out and touching this handle, which means that the surgery was contaminated, but he chose willingly not to speak up. And he was scared that he's going to be humiliated from that surgeon, that he maybe he's not going to get the residency of the surgery residency that he wants. By doing so, by not speaking up, he puts the patient under a severe risk of infection and sepsis. The important thing that we have to be aware of is that we work in an environment of shared knowledge, not one person knows everything. Everyone in the team have bits and pieces of information. And sometimes the most important information is not with the chair, it's not with the vice chair, it's not with the section head, not even the attending. The important piece of information that's going to affect the patient is going to be with our frontline workers, which is sometimes a medical student, the technician, the nurse, the resident. That's why if we want to protect the patient, we have to protect the well-being of those entitled to care for them. Of course, there is a big correlation between burnout, which is emotional exhaustion, depersonalization and low personal accomplishment among residents in healthcare. This particular paper, which was published in Medical Science Education in 2020, had this survey of 110 residents in University of California from various programs, some from pathology, some from pediatrics, some from radiology, some from surgery. And they give them this questionnaire about mistreatment, mistreatment anywhere from gender and racial discrimination to belittlement and humiliation. And they give them the mass slash burnout inventory, which is a standardized survey for prevalence of burnout. What they found out was that 42% of the residents witnessed mistreatment of the co-residents, 25% reported personal mistreatment. Those who reported personal mistreatment were eight times more likely to have burnout and four times more likely to report an anxiety and depression. They found no significant relationship between depression, burnout and anxiety, and the specialty, it doesn't matter if they were in surgery or in pathology. It didn't matter if they had student debt, it didn't matter the race and the gender. The most important finding, in my opinion, was that mistreatment is rarely reported to institutions due to fear of retaliation or believe that they will be ignored. So if a resident or a medical student approach you and tell you something is wrong, most likely this is just the tip of the iceberg. There is more going on and that's why we have to actively dig for psychological safety breaches. We have residents, we have medical students because we want to teach them, right? So one of the very important implications of psychological safety is on the learning ability. We have to understand the court of the people we are dealing with. For a medical student, for a resident to get where they are today, they have continuously proven their success. They might be perfectionist or overachievers. These cohorts are particularly susceptible for what we call imposter syndrome. What is imposter syndrome? It's chronic feelings of self-doubt and fear of being discovered as an intellectual fraud. Imposter syndrome makes them more sensitive to criticism and more aspiring, striving on being acknowledged and being validated. In early 1900s two pathologists called Yerks and Dotson had this experiment. They had mice and they gave this group of mice a small amount of electric shock. What they found was that this small amount of electric shock actually increased their learning ability and improved their performance. They were better able to actually perform the tasks that they wanted them to do. When they actually increased the intensity of the electric shock beyond a certain limit, the mice focused on the pain. Their learning ability markedly declined and they were not able to perform the task. That's when the Yerks-Dotson curve came out, which is actually the relationship between the performance efficiency and anxiety. An optimal level of stress like having an exam, taking an exam can help you focus on the task. Too much anxiety can impair your ability to concentrate and your performance begins to degrade. We see that in our residency programs when we're part of CC meetings, when we see a sudden dip in the performance of residents who were before that doing well. I personally call that the cycle of fear. They go on call, they make a mistake, they get shamed and blamed. Now they have this self-doubt. They go into an anxiety. Next time they're on call, they lose focus, more mistakes, and so on and so forth. The most important question, what can we do better in our programs? This is in a nutshell what we can do better at an institutional level, interpersonal level, and individual level. These are not islands. These are actually complementary, intercommunicated. In my opinion, institutional is the easiest to implement. Interpersonal is a little bit more difficult. The most difficult by far is the ones that are individual or personal level. The supporting mental health, financial assistance, childcare support, struggling residents, whether academically or professionally. I think each topic in these needs are one hour by itself. Today I'm going to, within maybe the next 20 minutes or 30 minutes, I'm going to focus on the institutional and the interpersonal level. I believe the most important is feedback. First, I'm going to start with, how can we train our residents to better receive negative feedback? When someone approaches me with a negative feedback, when someone approaches me and tells me, you're not doing this right, you have to fix it. The first thing that has to come to my mind is gratitude. The person actually takes the time, who cares enough, who takes the interpersonal risk. Like they are risking the relationship with me to tell me, I am doing something wrong and how to fix it. This person is a good guy. This is the person who cares about me. Second, we must have a growth mindset. A fixed mindset is that I made a mistake. I'm a failure. I give up. The growth mindset is I made a mistake. This is a learning opportunity. Next time I'm going to work on myself and I'm not going to repeat this mistake again. As Maya Angelou said, do the best you can until you know better than when you know better, do better. Emotional intelligence, they would tell you, when you face a flare of emotions, wait and identify your emotion. Name your emotion. You can navigate the feelings through this emotional wheel. Are you actually mad or embarrassed? Are you threatened or guilty? Are you overwhelmed or frustrated? Name your feeling. What are you feeling right now? And then forgive yourself. If somebody told you, I've never made a mistake in my life, they're not saying the truth. Everybody makes mistakes. We fail fast to succeed sooner. And then once we take all our time to actually absorb our feelings, know what's going on, and we must come make a plan. Make a plan before it's too late. If somebody told you on your first call that this was not the right thing to do, make a plan to fix it. Then, second thing is how can we deliver a negative feedback? We can use the six W's of investigation or we can say six W's of negative feedback. Before you give someone a negative feedback, ask yourself these six questions. Why am I giving this person the negative feedback to make them feel bad about themselves or to actually teach them something so that next time they would not repeat the mistake? Where am I giving the feedback? Is it in a safe place for both of us? Is it in my office? Is it where no one can hear? Or is it in a conference room? Or is it where in public or everybody can hear what I'm saying? Who am I giving the feedback to? What is my relationship with this person? And more importantly, what do I want this relationship with this person to be at the end of this conversation? At the end of the day, we are all colleagues, right? What are we saying? Are we saying how dare you? What year are you? How come an R3 doesn't know that? Or am I telling them, come, let's look at this case again. Tell me what you think about it. How are we giving the feedback is very important, because if I'm looking to somebody face to face, you know, I'm looking at their expression. Are they mad? Are they smiling? But if I'm sending, like, let's say a PAX chat or an email, there is a very big chance of misunderstanding. And when? When am I giving the feedback? Is it at 10 a.m. in the morning? Is it at a lunch break or at 2 a.m. when the whole world is collapsing? When they can't keep up, they can't open their eyes and they can't keep up with the list. The key elements of what we are going to say for an effective feedback is that it has to be specific, not vague or general, not limited to items per feedback. It has to be objective, of course, not judgmental or personal. It has to be constructive based on clear expectation. It has to be fair and honest. And most importantly, it has to be actionable, meaning that I told you you missed this finding in the Yota. Here is a paper or an article or a book about Yota with that. And by far, the most important thing when we as educators give a negative feedback to a learner, whether it's a medical student or a resident is empathy. What is empathy? The ability to understand and share the feelings, thoughts and experience of another person from their perspective. Put yourself in your learner's shoes. Demolizing the learner is going to have the opposite effect. This is a paper in the annals of New Zealand in surgery and they were talking about something very important. They were saying that the residents who are most in need of support, compassion and guidance and encouragement are actually the struggling residents. And if we have residents who is on probation or performance alert or they're not doing well, if we put them on do more pressure, it's going to have a totally different outcome. And another important thing that they talked about and quite frankly, some of us are actually guilty of it or maybe all is an observer bias. When I open a report from a resident on call, and I know that this person is atop of their class, they are doing very well, and I open the report and they're missing something in the back of my mind. Oh, most likely they had a bad night. Most likely there was lots of interruptions. This is not at all what's going to be if that same mistake was done by a resident who I know they're not doing well. So we have to avoid observer bias in judging performance of struggling residents. We can't stress enough on the importance of positive feedback. If you see something good, say something good. We, quite frankly, we do very well with focusing on negative feedback. When somebody is doing something wrong, we'll go to them and tell them, oh, fix this, but we're not doing a very good job when someone is doing something good, we tell them that they are doing something good. And as we said before, the cohort of the residents and the medical students we're dealing with are these overachievers and perfectionist. Positive feedback can boost the confidence and help combat imposter syndrome. Switching gears now to clear goals and educational strategies. These are four suggestions for strategies that we can give our medical students clear expectations and goals. First, preset expectations. If we can tell the residents before every rotation, these are the goals and objectives based on your level of training based on ACG and E guidelines that you're supposed to have. These are the milestones. These are the numbers of study that you are supposed to read based on your level of training. This is your responsibility. This is your working hour. You know, they, let's say they're supposed to work from 8 to 5, but if they have a moding conference, they are expected to be there at 9am. Other thing which we can help our residents with is structured learning agenda. We said that most of our residents are young millennials and Generation Z. These generations are tech savvy. They are used to getting information quickly through online. And if you go online, there is, there is multitude of information out there which can be confusing and overwhelming. If we can give our residents, let's say a four week structured curriculum with exactly what they're supposed to read per week, that's of course going to be very helpful. Other thing which some papers actually have found helpful and we have did the survey in our program is Meditation Evaluation. Giving formal or informal mid rotation feedback to the residents can help them actually know where they are, and if they are not doing well, they will have enough time in the rotation to improve. Of course, formal competency evaluation is an ACG requirement. All ACGME accredited programs must be doing this. They must have a CCC meeting, a CCC committee, clinical competency committee, which is responsible for formal evaluation of the performance of the residents based on ACGME milestones. These are very, very, like if we are planning to give our residents this structured agenda, this is a very good guide for us. The top 10 reading lists from Radiographics, it's beautiful. We can actually divide it based on speciality or rotation and give you basic and intermediate level, what radicals, radiographic articles, which is kind of addressing trainings, trainees or residents. Another thing, of course, is the Radiology Resident Collection Series. Again, these are divided by body parts and there are lots of videos in there that you can actually let the residents look at these videos. Also, the AOR, the APDR, through their, the Association of Program Director of Radiologists, through their education committee, I think they are about to come out with something similar to that with a structured learning agenda for all residents based on level of training and the rotation they are going into. Another thing we want to talk about is the Pygmalion Effect. We said that we want to give our residents clear expectations before the rotation, what is the number of study I'm supposed to read. We don't want to give them, we don't want to give an R1 on the first CT rotation, 40 studies per day, we're setting them for failure. They might not be able to do that. And also we don't want to tell them read four studies per day. You know, this Pygmalion Effect or self-fulfilling prophecy is that in education it says that learners do better with more is expected of them. Then we go to the reword, go to our reading rooms, our conference. How can we foster psychological safety in the learning space? First, in the reading room, this was a big chunk of what I'm saying now was very beautifully outlined in a paper by Dr. Diet and Dr. Patrick Lewis and Dr. Gadde. It's in the Journal of American College of Radiology that was published in 2023. First thing we want to do as educators is encourage inquiry. The learner's question reflects a knowledge gap that will affect patient care. I want the resident to ask me now when we are together staffing out the case, tell me the question that they have, admit that they have the stuff that they don't know, you know, so that that will affect how the performance when they buy themselves on call. So how can we do that? We want to, as we teach our residents in the reading room, we want to give follow-up non-intimidating questions to make sure that they understand what we are saying and actually encourage them to ask questions. It's okay to say I don't know. Other than that is modeling intellectual humility. What is intellectual humility is my awareness that there is limit to my own knowledge and that each encounter is a chance to gain knowledge. How can I model intellectual humility by simply admitting that there is stuff that I don't know? Like if I am as a junior attending, there is a case that I don't really, I'm not sure what the diagnosis is. It's okay to model humility and go ask a senior attending or let's say I'm reading a CT of the abdomen and there's something the spine that I don't know. It's okay to ask a new radiologist, admitting my own limitation can build trust and motivate trainees to admit knowledge gaps. Lastly, we have to actively explore psychological safety breaches. If there is a resident that appears emotionally distressed or disengaged, we want to actively go and ask them, how are you doing? Second conference setting. Of course, the diagnostic oral exam are back. So ABR, this, like all ones right now, they're going to take the new ABR oral exam and that's why we will have to go back to the hot seat sessions. So how can we cool the hot seat session? The first suggestion is to use the volunteer method, meaning that I don't have to call one person out. I can say I want an R2 and R3 and someone volunteer. If they're struggling, we can allow them to call a friend. If they're struggling, you can ask one of your colleagues. And then emphasize on the thought process. It's okay if they didn't reach the diagnosis, just tell them that the thought process was right. They described the lesion well. Don't give them 10 million MRI sequences. Just tell them, give them a couple of images or a couple of sequences and tell them maybe focus on the liver. The alternative would be, of course, the anonymous audience response system like Poll Everywhere. Other challenge that we have as educators when preparing for either didactic or case conference is the generation gap. We have millennials. I mean, we don't want to brush everybody like paint everybody with the same brush, but it is acknowledged that young millennials in particular have short attention span. So you kind of have to actively grab their attention, especially in didactic lectures. Generation Z are the first generation who are totally immersed in technology. They have no awareness of life before the internet, right? They are digital natives. They have information at their fingertips. So maybe we can always, even if we're giving a didactic lecture, we can make it more interesting by putting questions before and after. And there is something called gamification. It's an active type of learning like simulation or using games to actually or group case activities. And I think there is a site like the school Kahoot that actually can help us with gamification of our cases. Another thing is flipped classroom. The traditional classroom is actually when we give a didactic lecture and then the student or the learner goes home and studies. The flipped classroom is other way around. It can advance like online articles or videos to watch. And then the lecture can be dedicated to more case discussion or asking them for them to ask questions. And of course, we have to incorporate online and table based learning resources. Mentorship. Mentorship is a relation between a mentor and a mentee. And its effect is actually, it affects the mentee, the mentor and the program or the institute as a whole. For the mentee, it contributes to the wellness, career, growth and jobs, its faction. For the mentor, it's a personal expression of thanks for the past and hope for the future. It can keep this senior faculty up to date and help avoid their burnout. For the program, when they foster an effective mentor mentee program, they will have be rewarded with greater clinical and academic productivity. They will have high rates of faculty retention and promotion. The quality of a good mentee is that they embrace constructive feedback, be cognizant of the mentor's time, follow through on assigned tax and maintain optimism. They should also, it's expected that they show gratitude, appreciation, professionalism and ethical behavior. A good mentor and effective mentor is the one that shows enthusiasm, genuine concern and empathy about the mentee and availability. How can our programs build an effective mentor group? First, they have to encourage faculty to be mentors, reward them for their time, offer them protected time, funding, CME credit, put mentorship, incorporate mentorship as a criteria for promotion. Second, they have to do matchmaking. You have to match a mentor with a mentee that they share common interests. Both of them have to commit to confidentiality. Whatever happens, whatever is said between the mentor and mentee should stay confidential. Of course, representation for like unrepresented minorities. I mean, it's not crucial to match a female mentee to a female mentor, actually. As we know, we have only 26% of the radiologists as females, maybe 13% of them are in leadership position. If we're going to limit our female residents to only female radiologists, we're kind of limiting their chances. So it is good to match like the same cohort, if you would say, but it's not essential and also you can have more than one mentor. Mentors as sponsors. Sponsors actually take mentorship to the next level. They can put their mentee in the spotlight. They can support the application for a national committee. They can write strong letter of recommendation. They can personally use their power in their radiological society to nominate the mentees for talks at a regional or national level. Mentoring up is actually a concept. That actually is taken from the economic concept of managing up, meaning that the burden of the mentorship does not fall only on the mentor. The mentee has to share the responsibility. Mentoring up is basically a mentee-driven mentoring relationship. The mentee has to take the initiative to tell the mentor what are their goals and objectives from this mentorship relationship. What are the gaps in their knowledge and skills and set objective and attainable objectives and expectations. Lastly, online resources. We don't have to limit our residents or ourselves actually to just having mentors reason our institutes. There are plethora of online resources. In this paper actually there was by our prior residents, Elias Kikano and our current abdominal imaging attending Dr. Ramaya. They actually lay there beautifully all the resources that you can have if you need an online mentor. If you want to be a mentor or a mentee, you can go to one of these. There is the AOR, the RSNA, the SAR, if you want to sub-specialties like site of abdominal radiology and so on. As we said, big part of building a safe culture is having a good interpersonal relationship. How can we improve the interactions of our, like all the team. It doesn't have to be just resident radiologists, maybe technicians and nurses and admins. We can plan social activities together. This can be departmental or small groups. It can be an ice breaker, a low stress ice breaker where technologists and radiologists and residents meet together. Also, we can do meet and greet for new attendings. And in this meet and greet, we can put like videos for like staff communication, how to use nonverbal communications. And another important thing which is kind of, we as educators, we as radiologists as attendings, we want to know how well are we doing as far as communication. If we can provide as a program, anonymous, routine anonymous feedback to the radiologists, how well are they doing as far as communication with the residents and put it in a graph. Like if you get, if I get the feedback and I'm getting eight out of 10, is eight out of 10 a good thing? Or is most of the faculty is nine and nine out of 10? Or am I much better than everybody else? So that will actually help me know where I stand as far as psychological safety. We have to assess psychological safety. We have to actively assess psychological safety. And the first thing we have to know when we are assessing psychological safety, when we're asking the residents is something going wrong is that it has to be a bidirectional communication. Silence is a communication. You know, if somebody came and told me this is going wrong to me, to somebody else, this is a bad behavior, something abusive, abusive is happening. I must close the loop and go and tell that person, this is what we are trying to do. This is what we did. This is how we try to fix this problem. In the definition of psychological safety is that that person when they speak up, they're not going to be ignored. How can we assess psychological safety? We can, of course, we have to provide our residents or medical students a tool for anonymous feedback that they can send the feedback if they don't want to be known or identified. They can have this tool to actually give an anonymous feedback or a safety report without being identified. The other thing is that the fact that I never said that I don't want anybody not to approach me and tell me of something going on, that's not really how it has to be perceived. I have to actually actively tell them that I want to, I'm listening to you. I want to know if something is going wrong. Leadership Walkarounds is actually an institutional initiatives where leaders actively engage with frontline workers in various clinical settings to identify safety risks. They have to focus on accomplishment, recognition and reinforcement to build trust. Last psychological safety surveys. Residency programs have to send regular standardized anonymous surveys to assess safety, teamwork, work-life balance, burnout and depression. And there are several standardized surveys that can assess the psychological safety score survey or the mass slash burnout inventory. This was actually an example of a psychological safety survey that was published in the Journal of Patient Safety in 2022. It has this question that, through which we can use to assess psychological safety, is it difficult to speak up if I have a problem? Is it easy to ask questions when there is something that we don't understand? Are disagreements appropriately resolved? Does the culture make it easy to learn from errors? Is it difficult to discuss or speak up about errors? Are my suggestions taken seriously? Last but not least, radiologists as educators. We are human beings too. We are under stress, you know. I believe the biggest transition in our career is not really the first day in medical school. It's not really the first day in residency or fellowship. It is that day you transition from being a fellow to being an attending. This first day that you are actually there, you are signing the report, you are responsible for the list. And then on top of that, I have a first-year resident that I have to teach. We are not teaching our residents to be educators. We are teaching them to be radiologists, right? They know how to read, but they don't know how to educate. So, radiology programs, residency programs have to adopt a culture where it is important to, as part of their required scholarly activities, is education. We have to train, practice, provide feedback to our residents about being educators. We have to give them protected time to go and educate the junior residents and the medical students. Other than that, we have to optimize educational interactions. It is, I think, it has been mentioned before, I think at AOR meetings that some residency programs give a different list, assign a different reading list to attendings who are working with residents. It can be a lower volume working list so that they have more time, they have more time to actually teach the residents, give them protected time to prepare for lectures. As much as possible, decrease interruptions, phone calls, or anything that would affect efficiency. Career advancement, I mean, there is a most, I mean, every institute is different as far as their promotion, but I mean, I believe most of the time it's difficult to be promoted as an educator. In fact, Dr. Petra Lewis have in this known conference, she has a very, very, very, an excellent actually lecture talk about how to be promoted as an educator. I personally watched that twice. It is important to give us clear guide to how to be promoted as educators. You know, it's not just just about number of publications. I want to be my education activity to be taken into account. This will encourage more faculty to spend more time and effort educating residents. This will also encourage more faculty development, okay. We have to increase the awareness of importance of psychological safety. As we said before, give them individualized feedback. If we feel that they're not doing very well in their interpersonal communication, we can give them, provide them with training if needed be. At the end, I will leave you with this quote from Maya Angelou, people will forget what you said, people will forget what you did, but they will never forget what you made them feel. This is actually the paper, if you want to know more about psychological safety. This was a paper we recently published in academic ideology. It has much more details than what we just said in this talk. And thank you. Thank you so much, Dr. Mohammed for sharing your lecture today at this time will open the floor up for some questions. If folks want to ask a question you can put it into the Q&A feature. Sometimes it takes a couple of seconds. Questions to come in. Dr. Mohammed I'm curious what kinds of things in your own program have you been implementing in service of psychological safety and what's worked so far. I think building this anonymous surveys and giving them, we actually receive lots of these anonymous surveys that actually initiated by the residents. We also have these town halls, like it's just the education team and the residents together. We have formal and informal mentorship groups like we have, we kind of match, make our resident with an attending. And the way we do it is that if a resident tells me I'm interested in abdominal imaging they're going to go with an abdominal imaging attending but it doesn't have to be just this attending. They can freely actually pick any mentor that they want from the faculty. There's a lot of talk about burnout and across radiologists in any part of their career and wondering is there any advice on how medical students or residents can ask for accommodations or what this looks like in an environment where psychological safety is paramount and foremost. So burnout actually we have to give our first of all they have we have to give them the space to actually talk about it. You know, there is two ways, either we actually approach the resident who appear that they are disengaged or appear that they are depressed and actively asking them if there is something going on. Because burnout have so many, burnout have so many reasons you know it can it doesn't have to be just the workload right it doesn't have to be sometimes there's something going on in their personal life like a resident just had a new baby or somebody just got married or they need some time off you know something is going on in their life. So the first thing is actually actively listening. If somebody appears to be depressed or disengaged, we want to actually reach to them and ask them and try to try to listen to them and know what's what's going on. I think that's it for the questions. So I think we'll wrap there, Dr. Muhammad thank you again for this lecture and everyone else for being here and participating in this new conference we really appreciate it. You can access the recording of today's conference and all our previous new conferences by creating a free MRI online account. And be sure to join us again this week, Thursday, October 19 at 12pm Eastern, featuring Dr Stephen row for a lecture entitled current radio pharmaceutical serenastic applications and nuclear medicine. You can register for this free lecture at mr online calm, follow us on social media for updates on future new conferences. Thanks again Dr Muhammad and everyone else have a great day.