 Health care is complex, life is complex, suicide prevention is complex, but I truly believe that working together with our self-awareness, we can find a solution and implement solutions. For the sake of time, what I'd like to do now is just move into our panel session so you can get real advice, real feedback, have your questions answered by our esteemed panel. And the first person that I would like to direct my questions to is Dr. McCarran of UCI. Hi, Dr. McCarran. How are you? Good evening. Good evening, Bernadette. Good evening. Now, as you answer the questions, and maybe this is for each of our panel members, just briefly just go over anything that you want to say personally about yourself and some of the programs you may be working on so we can set a nice framework for our attendees. I'm going to give you three questions and just in a series of questions so you can just lump them together. And then so everyone will know is with the hill just Dr. McCarran and our other panel members will just continuously speak for about eight minutes or so. So my first thoughts are the film explores difficult and emotional subject matter obviously. And again, suicide is complex with no one cause and there are many warning signals that can be missed. How should suicide and mental health issues be discussed with students and healthcare workers who devote themselves to medicine? And how should self care be taught and reinforced in curriculum? And then finally, are the warning signs different for healthcare workers versus our other professions? And has COVID-19 increased the mental health issues due to isolation and other factors? Yeah, well, Bernadette, again, thanks for letting me be part of this. That's actually the first time I'd seen this documentary in entirety and it is sad. I mean, there's really no other way to put it. It's also concerning. But it's something that I know of, quick background. So I'm an internal medicine doctor and a psychiatrist. I finished my residency training in 2003. Right before I finished, there were no work restrictions in a little background. I would work routinely about 120, 125 hours a week for five years straight. And I've worked closely with medical students. I've been a residency training director for many years. And as a little bit of a disclosure, I do work at University of California, Irvine. And also, I also am part of the residency review committee for psychiatry with the ACGME. And we saw the ACGME listed here. So I want to note that and note also that my comments tonight are comments from me personally as a physician and not as a representative from UCI or from ACGME. Your questions are great questions and I think your first question is how do you talk to students and residents about suicide? And my answer to that, I think, is pretty simple and straightforward and that is directly. What I tell students all the time and pre-medical students and residents and early career physicians often is this. I say, this is hard work. This is hard work. And I view this and many physicians probably view this as a blessing. You know, it's a job where we get to really get to know people vocally and intimately. But it is hard work. You know, I think I thought back watching this documentary to the very first time I had to tell a family in the ICU in the room where their mother had just passed away and I had to explain what was happening in real time. And I was all by myself. It was one in the morning and no one had ever given me a class on it. There was no class. There was no instruction. And I just remember feeling deflated while it was happening and after for days and weeks. So I think as colleagues and as a community, it's best to speak plainly and directly about how this can be emotionally taxing. It can be difficult. It's uniquely difficult. I would say that physicians, students involved in health care are uniquely vulnerable, uniquely vulnerable. And so I would say we need to be direct, really direct. And I think we have moved in that direction. I would say over the last 20 years, we have a long way to go. But making sure that we look out for our trainees if they're working 80 often more hours per week is going to be important. The other question Bernadette, you asked me is our physicians and medical students in residence a little different when it comes to to non physicians, residents and students when it comes to suicide and getting help. And my quick answer is yes, with an explanation point. There are many reasons why perhaps I think some of the reasons might include the following. Number one, I think that people in this cohort, this profession, you know, don't have it within themselves culturally right because we join a culture when we're in medicine to routinely or easily ask for help and say that they need help. So maybe that's changing. I see some evidence that that's changing with with with many more opportunities than I had as a medical student to to get help and to to talk about depression and anxiety. For example, I know Dr. McCrae my my own institution UCI goes out of her way. I mean, I probably weekly I'm seeing emails to our residents to to our trainees saying, if you need help, this is where you go. This is how you do it. And so I'm seeing some changes. But really the culture is we are fixers. We are supposed to be healers. And sometimes it gets in the way if we're depressed and we're anxious and it just gets sidelined until it's too late. So I think we are in a unique situation and I'm really glad that that Bernadette that you and Monica and the others put this together. I think it's so important to start the discussion. So, and I'm really grateful to be part of it actually. Thank you, Dr. McCarran what I thought was interesting also is what you highlighted. And that's a big subject is culture. Because I heard you say the hesitancy to ask for help and creating those cultures where residents and fellows feel feel safe enough to ask for help when they need it, and having peers or or other superiors to be able to go to. So, you know, maybe that's something else that we can talk about later. I don't know if you have any more comments on that subject or. Yeah, I mean, I think it's a it's a culture not only a fear of getting caught and have me losing your license, but I think it's just a culture of us being in the position of healing the depression and healing the anxiety and healing the suicidal thoughts and not having them. Right. And I think that that's just that's just that's just part of the that's just part of the culture and analogy might be, you know, the plumber, you know, fixes plumbing stuff. But if something happens that plumbers house, you know, it's it's different it's it feels different right because it's happening to them right and so they have to deal with the plumbing issue at their house. And with with physicians and health providers in the field, you know, we go to work and it's just it's ingrained in who we are it's ingrained in our in our culture and who we are and, you know, to heal and it's often difficult to to stop and say, Well, wait a minute, I think I might need some healing. I might need some help. And I think we're making some progress over time slowly incrementally. But but I but I think that that culture is strong. I think it's strong. Thank you. Yeah, I definitely from my own personal experience, I think you just don't know if somebody's having those thoughts or if they're depressed so creating a safe environment and starting early with that type of culture so so important. Thank you so much. Dr Smith, I would love to ask you. I know you do some coaching as well you're in this film, which is very commendable. And talking about the mental well being of our residents and fellows and other health care workers. And how is that connected with the ability to provide excellent patient care. And then also on the other side, how is that connected to patient harm. And then my other question is, it's understood that not seeking help we can become, you know, someone can become overwhelmed. And which we saw in the film delusion in their work, burnout and serious conditions. What are the barriers for the health care workers to go out and seek that help. I know we talked a little bit earlier about the culture and some other things but what are what are the barriers that you you have identified. I think that's a really good and important question, right is to observe it's it's the water in which we swim. You know you can't really see it because you're in it you don't really recognize it. But really we are living in a society and a culture where there's a lot of stigma for mental health help and for saying that you're struggling at all. So I think de stigmatizing mental illness de stigmatizing distress I mean the data is half of us, half of us are burned out. So why are we acting like we're not. And so I think people have talked to only recently like when I filmed this, it was about maybe three years ago or so. And I had not I had just lost a student to suicide. And I had not yet become comfortable talking about how deeply and profoundly that affected me and how my own thoughts were intrusive. And it was incredibly difficult to live in my body with those thoughts coming so commonly and intrusively. And then I went what happened to me for instance as an example is I went to at a conference that I was hosting at Mount Sinai I was one of the hosts. And someone spoke who was a suicide expert and he said we need to stop other ring. We need to say we need to stop saying here's the data on physician distress and suicide. We need to stop looking at like other physicians and we need leaders to stand up and say I I had this. You're not alone. There's nothing wrong with you. You're human. And so he said that and he showed this film actually clips from it and I co-facilitated a workshop with him right afterwards and for the first time ever. This was maybe one or two years ago. And I was like me too. Me too. And I'm going to tell every dean because it was a conference of deans and directors. I was like me too. And I'm going to go back to my institution and I'm going to sit in front of the lecture hall and I'm going to tell the students. I'm going to tell everyone right like we need to destigmatize this. I'm a full professor. A very respected person at my university. And we need to say hey look it's okay. I can still practice clinical medicine. I can still be an esteemed professor. And we're working nationally people are working on it because every state has their own licensing questions. There's a lot of fear around those licensing questions and wondering what might happen if you seek treatment if you seek medication. And I think a lot of that is over amplified in a physician's mind that or in a medical students mind. I advised historically I advise medical students for a living and in my role at the university. And so they would feel if they took a year off or a block off or a week off that they would be forever stigmatized and we just had match day. And those students who took a year off even for mental health issues. I mean every program director knows this is just a fact of life of being in medicine. And as long as you have your story of like I was struggling I got help I'm so much better. I have all the tools now. Right. Someone who struggled and is on the other side is actually better because they know the tools. They know they can access resources. So I think that it's almost there is stigma, but there's also sort of like this false belief about amplifying or over amplifying the stigma that's there. I think that's one of the biggest barriers. And I think particularly during the pandemic it's been an incredible opportunity for physicians to speak up and say and try to help each other first of all and say look, we are hurting. We are suffering. We have PTSD. We are depressed and there's a national physician support line that's all volunteer that many of my friends and colleagues psychiatrist volunteer for. It's available to physicians not just to her suicidal, not just to her who are depressed or have anxiety or PTSD, but are like, I just kind of can't take it anymore. And just reach out. And like we have in the comments here in the q&a there's like, I'm in attending there's no duty hours for me. Right. Like, yes, we are human beings and like the numbers that this person puts in here. 11 patients per half day 80 unopened inbox messages like I typically had 100 inbox messages at all times. Like it's in the human, the demands that they put on us. And I think it's up to us now to believe that now is the time particularly with the attention on physicians during this pandemic to say, we're human too. We can't do this anymore. This is not good for us. And it's not good for society to continue to ask us to do this. So those are my thoughts. Thank you very, very much for those thoughts and what you shared. One of the things that I was thinking about while you were talking is, you know, the stigma, you know, the word suicide is just scary. You know, it's one of our biggest fears. It's an unbelievable, no one even can comprehend it, nor want to live through it. So let alone that you may have those thoughts makes it even more compounded. And I think you're correct about the culture currently with COVID, you know, with every downside there's always a great upside and to take advantage of that upside. And I think that, you know, this is a good example of taking advantage of that upside and really, you know, with the wave of talking about mental health issues. Now, I think this is very, very helpful. So thank you and your resources later if you'd like to post those those mental health resources would be really great. Thank you so much. So, Dr. McRae, you do a lot of programs at UCI with wellness for the faculty and the residents and their programs. Can you please tell us about some lessons that you've learned some failures and successes of actually reaching out and getting that type of culture moving forward and getting the residents and faculty to talk about mental health and wellness. And then you can conclude by talking to us maybe giving some advice or three top initiatives that somebody that's listening right now could start to implement or bring to a meeting or get their team to rally around and that could be faculty or students as well. Thank you, Bernadette, for inviting me to be on this panel. It's an honor to be here and it's an important, important topic I'm pushing my heart, and it was great to hear what Robert and Sonny were sharing. And I just wanted to echo some of the beans that they touched upon in terms of changing the culture. And Robert's right that Dr. McRae, I'm sorry, is right that we look at ourselves as being fixers. And it's really hard to release that role and ask for help. And also during this COVID pandemic, as Dr. Smith was talking about, we were reinforcing the pressure that is placed on physicians calling physicians heroes. I mean, again, it places more pressure. You're not supposed to be asking for help. So working on changing the culture is number one. And it's going to be ongoing hard work, but something that has to be done. And second, regularly engaging leadership in the discussion and the actual work on our well-being initiatives. Those are the two critical pieces to this changing culture and engaging leadership and looking at this as an institutional problem and something that we're going to fix as an institution and also as the culture of medicine. We really have to shift the way we look at others and destigmatize mental health. Some examples of what we've been doing over at UC Irvine. Three of our largest residency programs have started to do automatic check-in sessions. Semi-annoy for our residents with a psychiatrist. The residents have the ability to opt out, but these appointments are automatically made regularly. And I would say the vast majority go, and it just allows the residents of those to get connected to someone. A psychiatrist, a therapist makes them feel more comfortable accessing their health when it might be needed in the future. And also it helps destigmatize mental health and makes it okay for us to ask for help and recognize the stressors that we're under. We also developed a faculty peer support program. We had Dr. Jerry Shapiro from Brigham and Women's come over and train faculty. She found that the peer support program over at Brigham and Women's is one of the first of these kind of programs in the nation. This program has physicians proactively reaching out to their colleagues. We're going through an emotionally distressed event, so it could be that there was a medical error with an impact on someone. So this faculty member that's attending may not otherwise talk to anyone or seek any support, but this is just, we're proactively reaching out to our colleagues. And we try to open the door, start the dialogue, get them permission to talk in a confidential safe space. Again, otherwise these physicians will just try to power through and not say anything. We also are coordinating debriefing sessions for the entire healthcare team, 24 to 40 hours after an emotionally distressed event involving a patient, or trying to create again that safe space to process what happened. We also have an interactive screening program that's hosted by the American Foundation for Suicide Prevention. This gives residents and faculty an opportunity to anonymously complete an online screening, so it will just take a few minutes. And then within 24 hours, we have a counselor at UCI review their responses, and then they directly connect, well through the website, so it truly is anonymous, they connect with that person, they give him some resources, but also an opportunity to meet in person. So we have counselors at UC Irvine, and she actually provides services to all of UC Irvine employees. And it's a lot. The residents actually make up 30% of her caseload, and it's a lot. But what I will highlight is that I think that this screening program that's given to everyone is actually letting people know about this resource and they're utilizing it. So I am glad that they are. We're also working on forming partnerships in the community to make sure that mental health services are easily accessible in a timely manner. As Dr. McCarran was saying, I mean, the residents will just keep pushing and pushing, physicians will keep pushing and pushing, and they won't make time for themselves. And so we need to make sure that they do have an easy time to make the appointment when needed. So we have at UCI psychiatry, residents and faculty can directly email the medical director to schedule an appointment rather than going through the front desk. And then we also have one of our mental health practices in the community have an appointment line just for UCI providers, so someone will pick up immediately. And then education and just continuing the dialogue, reducing the stigma, and we're trying to build the culture that physicians are not supposed to just monitor for signs and symptoms of depression, or risk of harm in themselves, but also they have a responsibility to look out for each other. I want people to reach out, speak out. We need to have that dialogue going. In terms of recommendations for others who may want to start programs at their institutions, it's really getting leadership engaged. To get the financial support you need real FTEs, real money to back positions with protected time to wellness. It can't just be people volunteering their time you have to get money behind of this. Money behind people to have the time to devote to this important initiative but also funding to support various events and activities. But in addition, we do want well being champions within each department. Thank you Dr. McRae. I have a question you what everything that you spoke of was very detailed, very in depth, very thorough, which was is fantastic. And that is a lot, a lot of work and and I just had this the random thought it was, has there ever been any type of template? Is there any, have you ever put this down in a paper or in any documentation that can be used as a guide? I'm not personally, however, that being said, the National Academy of Medicine, ACGME, DLAMC, all of them have these great great banks of resources and they have guides as well. So fortunately, physician well being is at the forefront in terms of many of these national organizations focus. So there's a lot of information out there. Okay, great. Thank you. And what I'd like to do now is see if our panelists have any other comments or thoughts and and see if we can get some questions from our participants or attendees to see if they would like to ask our panelists any questions. So first, are there any other thoughts by our panelists? I had the thought. While the last person Dr. McCrae was just speaking about the universal screening and the anonymous availability of that people who are interested here if they want to implement that they can go to the American Foundation for Suicide Prevention and they look about the screening tool and work with them. We use that at our university as well and my friends and colleagues implemented it and you never think you're going to be the one who's going to need it, right? Like, oh yeah, we fill this out all the time, right? And I literally not only was colleagues and presented and have published academic journals, right? With the people who create and implement these systems. I also became a recipient of that where I the anonymity of it to me at first because when you're in shame and stigma, you can't see it's okay to get help. So I went to the anonymous system. I made a fake email. I made a new Gmail account, right? I did all the things. I didn't want anyone to know it was me. And it got me help. And now I can speak, right? So like I think the pervasiveness of those anonymous things and the multiple ways in that she had talked about some for some people peer support feels safer. For some people an off-campus therapist feels safer. For some people, someone labeled a coach feels safer. Like any way in to help seeking behavior and normalizing help seeking behavior is the goal. So I just wanted to speak to she has this like platter of different ways that people can get help. And I think that that's important too. And I really just want to echo what she said about put real FTEs. This isn't about like, you know, a gathering, not that we're gathering because of COVID, but this isn't about like one thing. This is like this. This is the time to ask our institutions to really step up. I was actually thank you for articulating that so well because I was thinking about that as well when Dr. McRae said that I thought, wow, that is that's almost clever. That is so brilliant to really introduce this and really stay in check with your residents with the screening program. And obviously it works well. Any other thoughts from our panelists? Okay, let's open it up for Q&A and I'm looking over here on the right side. And there's a question from Susan Lee from to the panelists. And it states, are you aware of any other medical schools that have this proactive help available for their residents? Which ones do also the documentary mentions that medical schools surveys among their medical students rates of depression rates and anxiety. How can the general public or prospective medical students access this information? Anybody would like to take that one on? I'm happy to I'm always more than happy to speak so feel free to keep me in check. But I mean, this is a problem at every medical school. There is no medical school where this is not a problem. This is a problem of the culture of medicine. So there's a randomized control trial that shows that around 20% of interns within three months are having suicidal ideation. So within three months, you know, they had just matched. They had the best day of their life. It's like the moment that is the culmination of all your hard work. You're so happy. We throw you an internship three months later. One in five is entertaining the thought they'd rather be dead than continue in their internship. This is a systemic pervasive problem. There are many, many studies that over the course of 50 years internationally across medicine showing the rates of suicide and depression and burnout and they're published in JAMA mainstream articles. This is not a new problem. This is not a local problem. If you have a loved one in medical school, chances are there is significant distress where they are. So and do other schools have programs like Mount Sinai where I was, they require. It's an opt out mental health screening and just like UC Irvine is one of the leaders as well. There's many schools that are coming together to try to lead this movement, but there's a lot of work left to be done. Thank you. Would you with Dr. McCarron or do you know what like to add on? In terms of the question regarding where do you get the information regarding the medical students rates of depression rates of anxiety? It's a good question. You know, we are trying hard to gather data in terms of how we're doing at UC Irvine and we put out surveys each year. But you know, it's difficult, you know, there's response wise, you don't know who's answering the questions. So we get a general sense of how we're doing, but it's, you know, we can always continue to work harder. And unfortunately, like Dr. Smith said, this is a problem everywhere. So I don't know of where that would be available to the public. And then again, as Dr. Smith says, schools are working on being more proactive and providing support because I think we're all realizing that people aren't necessarily going to ask for help themselves. So we need to just place the resources right there and make the appointments and they cannot doubt if they want. You know, in Bernadette, I would just add that I would say 10 years ago, you know, when residents and faculty were filling out surveys about how their residency program is doing, there was no wellness in there. The word was not used, right? I mean, certainly when I was a resident, I was like, what's wellness? You know, I'm tired, you know. But fast forward to today, and it's a slowly evolving process. You know, wellness is a big part of the evaluation of how our residency is doing. It's integral to, you know, the success, you know, at least on paper. Again, I think we have a long ways to go, but finally we're starting to include ideas of provider wellness when we're evaluating training programs and medicine, which is a good thing. And I'd also add that it's interesting there's the, like, incidence prevalence, but there's also the utilization data. And at our medical school, we actually, for many years, have looked at it as a good thing when utilization of mental health resources goes up, because we think that means that they're actually addressing the issue. So we don't want, like, we want the incidence and the prevalence to go down, of course, but we want utilization of psychiatric services. We want that number to go up. Absolutely agree, Dr. Smith. I get monthly reports from some of our key practices and therapists. I mean, obviously they're not sending me names, but they'll just say, I just want a sense of the utilization rate from month to month. And it does comfort me to know that people are using the services because we know that it's a problem and I would rather have high utilization rate. Totally agree. One question I did have. When you do have incidents, do you have a certain protocol that you have in place or is that highly recommended that is also included in your programs? 100%, you can go to the American Foundation for Suicide Prevention website and find what to do after an event, what to do after a suicide. It includes immediately after a suicide and for the leaders of the organization, they also have one for high school. I mean, we had to implement those protocols. It's horrifically painful. Suicide contagion is very real. It is very real. It is very important to talk about it as soon as it happens as openly and with as much support as possible from day one. Yeah, agree. It's something that I think a lot of institutions just don't want to think about it, but you have to. One topic that I present at different conferences is how to have a crisis intervention plan in place. It's like not the work that people want to do, but you've got to have it in place. And then we also have a protocol in terms of like the level of urgency and what are all the resources. So if you need to see someone now, this is what you do. If it's urgent but not imminent danger, then this is what you do. So we have different tiers, bank of resources. Could you speak to maybe this is a question for Dr. McCarran a little bit about the peer-to-peer relationship and the support system there or peer-to-peer training? Yeah, you know, well, I mean, I think it's lacking generally speaking in academia and probably in community programs as well. You know, there are ballot groups that some institutions can use either formally or informally. And these are groups where, you know, providers can come together and talk about the badness at work, the struggles, the strain, the uncertainty. You know, that happens in the world of medicine. I don't really see a lot of those happening, you know, in academia and I see Sunny nodding her head to the affirmative. And I think they should happen more. I don't necessarily think they should even be officially organized by an institution. I think that they should be organically created when possible and supported. I don't think there's really a lot of peer-to-peer support, unfortunately. Now, examples of peer-to-peer support, I think in institutions that I've been at at UC Davis and also at UC Irvine would be immediately after a suicide. A lot of institutions will kind of want to shy away from it. Fortunately, those two institutions that I've been with have faced it head-on and quickly and in a very, very supportive way. They don't waste a minute. And that's when peer-to-peer support has really, I think, been strong from what I've seen in academia. It would be nice to do it in a preventive way, though, you know, if that's possible. And again, I think that's one way as an institution, as a profession, we can probably improve. Thank you. You know, we have a couple more minutes and I don't see too many more questions from our audience. So, oh, somebody did ask about nurses and wonder what the pressure is like for nurses and any data. And I'm also wondering about the opiate use by doctors. Would anybody would like to address that question? I, you know, so I can talk a little bit about opioid use or misuse. You know, it's prevalent. I thought in my head I can't give numbers, but it's pretty substantial. But that's also often commingled with misuse of other substances like alcohol pretty commonly, which is not good personally for the providers, but also professionally. It can be obviously problematic as well. You know, and so, I mean, chronic pain is the number one reason for a YA patient is going to present to a provider pain, physical pain. And as providers, we're also humans, so we're going to have pain as well. It often just difficult to deal with it. We also have more access to it as well. So we have more access to pain medications, narcotics scheduled pain medications as well. Bernadette, I'd like to ask the panel, we have a couple of questions around fatigue management and communication bombardment. How do you deal? How do you cope with so much coming at you and work on your mental well-being? The information overload, the documentation overload, the nonstop email inbox, that is a challenge. What I have personally been doing is if I leave my schedule open, I'm going to get scheduled for a meeting every hour on the hour. So I actually schedule just admin time for myself and I schedule the time when I'm going to go work out. I'm obsessed with scheduling everything, but if I don't, it's endless, right? And so I'm trying to also change my mindset that it's okay when there's a bunch of emails sitting in my inbox and they're unread, it's bothersome. But it's never ending at the same time, so it's just kind of getting used to that and being okay with not responding within six hours. I mean, I think the expectations have gotten a bit ridiculous in terms of email. It's almost like you're texting, so you should respond right away. And it's okay when things just kind of sit and being just having that mindset that that's okay. It's been tough, but that's what I'm personally trying to do. Dina, that's hard to do for so many of myself included, but I fully agree. I mean, I think using an analogy, someone coming in, they haven't seen their doctor in 15 years and their blood pressure is really high. Their diastolic blood pressure is 110 or 115. It's our impulse to say, oh my gosh, we got to get this blood pressure down now without thinking this patient's had this high blood pressure for years and years. Let's do it slowly. Let's do it in a sustainable fashion. And sometimes it's okay for inboxes full. No one's going to be hurt from that if they get a delayed email response to be one with that. And it's hard to do, but that would be my suggestion. And then the other thing is, let's say you're working at an institution where you're getting tons and tons of EMR inbox messages that you don't have the support you need. And you're seeing patients every 12 to 18 minutes. Well, maybe that's not sustainable. Maybe that's not sustainable for a particular individual at a particular job. So that's another thought. I think that's some wisdom that I'll just echo there is that the current healthcare system is not sustainable. It is for human beings to spend 40 years right of their career in their life with an inbox with 100 things in it and expected to see someone every 12 minutes. It's just not sustainable. I think that this the place that we are right now in healthcare is an accident of history. Our insurance system is an accident of history. The EHRs were kind of rushed out in 2008 because of the American Reinvestment Recovery Act rights with some bonus money to revitalize the economy. And one analogy we use is we would never ask a judge to be the court reporter. It wouldn't even make any sense for the judge to go home at night and type up what happened. While their kids are being fed dinner and after they go to bed. So that's because we protected the judges as they developed right over time they've been around for centuries just like healers have been around for centuries. But for some reason through some odd be perhaps because we're so used to self sacrifice and whatever you put on us we work harder we'll work faster we can do it we can do it. But it just doesn't make sense. For your physician to go home and a day or a week later be charting on what happened during that visit. And it takes away from our families from our children. Doctoring when children now imitate doctoring I don't know if any of you guys have this in your household but I do in mind. My son when he imitates doctoring he gets out his computer and starts typing. That's not what doctoring is. We are the most valuable resource in health care. That became even more obvious during COVID. We could get some more ventilators right that came over from other nations they would fly them into Italy. It's the human beings who can operate those ventilators that can't be made overnight or in a week or in a month or in a year. We are uniquely valuable resources and we've become the most expensive data entry clerks who are willing to work 24 hours or 18 hours. Again this doesn't happen in any other industry. Why do we allow it in medicine. It's fascinating and it's time to start asking those deeper questions I think. Very well said. And as we're moving to conclusion of tonight's program. Perhaps with the way you kind of teed that up Doctor Smith I'd like to ask our panelists you know if you had just one wish list. You know so we can in a nice positive note what would that be what would that be to really help our physicians and our health care workers. With their mental health issues and any wellness programs. Because like you said we do need them and we do need all of you so thank you again for participating so if you'd like to just maybe one by one answer that question that would be wonderful. Sure I'd be happy to I think about this all the time so I'm happy to share my wish list. I would love a wellness center with therapists and psychiatrist dedicated solely to our physicians available 24 seven that's my wish list. And then you just kind of walk through the door and it's really confidential and comfortable there. The other item on my wish list is that there is enough ancillary staff support staff so that the physicians can focus just on the active doctoring or focus on just their education. Sunny I'll be brief and let me just say that I really heard what you said and I've never thought about it that way before so I'm going to be thinking tonight about what you said. My wish list would be kind of different it would be to look to relook reassess at how we can most effectively meaningfully and sustainably optimize the practice of medicine. And if we do that, I think it means wellness for providers. I believe that and I think if you if you truly are optimizing medicine, then you're going to optimize wellness for providers. I think it goes together and in some ways I think we're missing the mark and that that would be my wish list. I would say for me, I think it all starts with seeing the physician as a human being, because we asked them to do things that are really not human we treat them like robots and machines and cogs and wheels and I recently in my coaching program we invited in Martha Beck who's like an incredibly well known coach, Oprah's coach, etc. She spent two Saturdays with us doing workshops, and then she later said, those were the most profound two workshops of my career. Because she could not believe the things that the physicians were telling her that we were asked to do, or that we implicitly did without being asked, coming to work while you're having a miscarriage, coming to work while someone is having surgery that you love, not going pee, not eating, not like all the things that so many physicians believe is the right way to be a good doctor. I think is by denying a little bit of our humanity. Yesterday in my group, someone wrote concern because her manager was concerned that people complained they saw her taking a 10 minute walk. 10 minute walk literally actually objectively people complained because they thought that meant she wasn't working hard enough. She's like I work through my lunch every single day. I chart every single day at lunch. People don't quite realize physicians don't get lunch, at least for the most part. Yes, there's many who do, but they are kind of the rare exception. We chart at lunch. We are always working, always working. So it's just that's the culture that we're in. And I think starting to give us enough space to realize that we need all the breaks everyone else does. We need all the compassion everyone else does. We were called residents back in the day because we lived in the hospital. We no longer live in the hospital, but there's just a lot of that has been carried forward about the way in which they addressed in this documentary. And even as a woman, for instance, medicine used to be practiced by men who had stay at home moms carrying for all the stuff. And that's no longer the case. So it's like, how do you change everything when all of society has changed, but the rules for how we doctor hasn't really changed. So those are my reflections. Well, again, I'm speechless and I really, really thank you all from the bottom of my heart. You've contributed so much and I hope our guests have heard quite a bit from you and learned something and are motivated to move forward and continue the conversation. Because we know the conversation does save lives. And again, as your moderator, I thank you for this honor. And I'd like to turn the program back to Monica McDade. Thank you, Bernadette. Wow. Blessings and thank you to all of our panelists. Incredible job, Dr. Smith, Dr. McCarran, Dr. McCray. Really appreciate your expertise and sharing your wisdom and your compassion. Bernadette, I know this is a subject near and dear to both our hearts. I lost a brother 36 years ago, who I still think of every day. He wasn't a physician, but the act of suicide. It only takes a moment, but it lasts a lifetime for the loved ones left behind. So from all of our hearts to yours, I hope that you will be able to start a dialogue with someone and reach out if you think someone is struggling. We will be sending out a survey as well. And if you do feel inspired to make change, please consider a donation. Many of the proceeds from tonight's screening will be used to update our mental health actionable patient safety solutions on our website. So we want to make sure that they're refreshed and current and relevant to physicians and nurses in today's working world. Thank you to all of our attendees. We really appreciate your registrations and we hope to see you at our next event online. So with that, enjoy the rest of your evening. Thank you.