All right. Welcome, everybody. Hi, I'm Allison Capizzi. I'm a staff physician at VA Palo Alto in California. And thank you for joining us today for our talk on burnout in PM&R. I'm joined today by a number of people who are passionate about this topic, so I want to go ahead and introduce them. I'm joined by Dr. Allison Bean, who is an assistant professor in sports medicine at UPMC in Pittsburgh. Dr. Dana Yorks, who's a sports medicine fellow at Shirley Ryan Ability Lab in Chicago. And Dr. Monica Verdusco Gutierrez, who's professor and chair of the Department of Physical Medicine and Rehabilitation at UT San Antonio. Starting off with disclosures. None of us have any disclosures relevant to the content of this talk. And I do want to say this is meant to be a review of recent literature in this topic and then to talk more broadly and open up the discussion to you all. So what I'd like for you to do as we're going through the presentation is to put your comments in the chat box. And then Dr. Yorks is going to moderate our discussion at the very end. So as you think of things, please share in the chat box. Okay. So, one second while I get control over the slides. Okay, awesome. Yeah, just bear with us as sometimes there's things that come up while we're on zoom but I'm sure you're all familiar by now so here's our outline for our talk today we're going to overview the topic. We're going to discuss research in trainees, we're going to discuss research on burnout and women and PM&R. We're going to talk about exercise and wellness, as it pertains to burnout. We're going to introduce the collaborative PM&R wellness project which is an effort between AAPM&R, AAP and ABPM&R, and then we're going to have our discussion. Okay. So let's open up with a poll. Whoever's joining this conversation we're going to have a poll pop up on your screen, and I want you to tell us what what represents you. You medical student, resident, do we have attendings in the audience. So go ahead and make your selection. And submit. Okay. And then we'll go ahead and post the results. Assuming that people have been able to take the poll. Awesome. Okay. Thanks for joining everybody so we actually we have medical student representation that's fantastic because we are going to talk about trainees and burnout. So thank you for participating. This is a good representation. Okay, so I'm going to move on. So introducing the topic. This is something I think we're all familiar with, at this point because it's become epidemic in our society, but burnout is a chronic workplace stress syndrome, and it's characterized by these three things is emotional exhaustion depersonalization reduced professional efficacy. And this isn't something that just affects the individual right this is something that affects patients. And this is something that also affects our institutions so on the right hand side of the screen, just some examples of the financial impact to institutions that are hiring physicians that are experiencing burnout. So it's significant. So burnout is complicated there's many driver dimensions. This is from a publication from Mayo in 2017 from Dr Shana felt and colleagues, looking, it's a really good dive into the problem of burnout. And looking at the issue. There's things like meaning and work well meaning and work is something that we all, you know, find really important to us, and can lead to engagement but can also lead to problems like burnout. So it's complicated. And most institutions have taken the approach to try and address the issue have created committees dedicated to wellness dedicated to this problem. The thing is that, is it really the right approach, you know, are these committees really able to solve the problem are things like offering yoga classes, really addressing the root issue and most of us feel like it's not. It's not really addressing the root issue. And there's been publications again this is from the Mayo publication in 2017, showing that there's systemic change that needs to happen and this comes from the nine organizational strategies to reduce burnout. But it can be difficult for institutions to implement these things, and that's something we want to talk about. So, in talking about burnout there's another term that's probably a better thing to use rather than the term burnout because burnout puts the onus on the individual that's experiencing it. And we know physicians are resilient we've proven that over our training we've proven that in our work, it's challenging we keep coming back. So the real issue is, you know, at least in, in some recent literature, is that we want to help people right i mean we want it we go into medicine to help people, but we get out into the real world, and there's a whole business of medicine that we have to contend with. And that puts us at this place where it's difficult to take the patients, what the patient really needs up against what an institution needs or what the business needs, which can then lead to these feelings of depersonalization and, and a real issue so it's not really the individual that's the problem. It's this whole system and the moral injury that results. So, looking at the 2021 medscape survey. This was published recently and looks at all these different specialties right so not just PM&R, which we're going to go into, you know, burnout and PM&R, but across the subspecialty board you see physical medicine I will say that these surveys tend to be pretty heavy on internal medicine specialties and PM&R is not necessarily well represented. So it's possible that our levels of burnout are higher than are what portrayed on the screen. This comes from our board so AVPM&R looking at burnout specifically in PM&R physicians, and it had a pretty large sample size 1500 people completed this survey, and of those people, about half fulfilled the definition of burnout, so a pretty severe issue and of the people who filled out this survey they identified the top causes of burnout being things like regulatory demands, the amount of work that we're doing, and practice inefficiencies or lack of resources and working more hours per week was associated with the higher frequency of burnout. I wanted to touch on COVID-19 because this has clearly impacted everyone in the audience, and there is some data on COVID-19 and burnout. So how has it affected work-life happiness? You can see the blue bar, or the blue bar, the purple bar shows current sentiment and the teal bar, blue bar, whatever you can see on your screen below shows pre-pandemic sentiment. So more people are saying that they feel more unhappy about work-life since the pandemic started, but when you ask people whether their burnout began before or after the start of the COVID-19 pandemic, most people will say before. Perhaps it's just been exacerbated by the pandemic. And if you are more interested in this topic, I want to point you to my colleague, Dr. Verdusco-Gutierrez and others have created this poster on financial stress during COVID-19 and how it impacts physician burnout in PM&R, so please visit their poster. And now I'm going to hand this over to Dr. Bean to talk about burnout in trainees. All right. Thank you, Dr. Capese. Trying to just take that control here. All right. So I wanted to talk a little bit about burnout in trainees. So burnout in medicine in general starts quite early. This cross-sectional study by Dervia and Steinefeld's group in 2014 found that over 50% of students in medicine were experiencing burnout, and also similar numbers were found to be experiencing either high fatigue, as well as screening positive for depression. And very concerningly, almost 10% of medical students expressed suicidal ideation within the last year. I don't have any more updated data, but I can't imagine that it's particularly improved over the past five or six years. And I also wanted to spend some time today talking more about a publication that my colleagues, Allison Schrader and Kevin Francis, as well as several others, including Dr. Verdusco-Gutierrez, this publication just recently came out in AJPM&R. And this was looking at burnout in PM&R residents in the United States. So prior to the pandemic, what we did is we surveyed all U.S. PM&R residents in the country in order to determine whether or not they were experiencing burnout. And this was looking at burnout in PM&R residents in the United States. So prior to the pandemic, what we did is we surveyed all U.S. PM&R residents in the country in order to determine not only how many residents were actually burned out, but also what factors might be associated with higher levels of burnout. Because we can do all these epidemiological studies, but if we're not moving towards understanding why the problem is the way it is, then we're never going to be able to have concrete things that we can take to the system level in order to improve burnout among both residents as well as future physiatrists. So in this study, we received nearly 25% response rate, which we felt was pretty good. And what we found was a little bit lower than the ADPM&R study, but we found that a little over a third of residents reported feeling symptoms of burnout. Some of the main components of burnout that they experienced were emotional exhaustion was 30%, while 21% experienced depersonalization, and obviously there's significant overlap in some of the trainees as well who were experiencing burnout. So this is typical of what we see in medicine where emotional exhaustion tends to outrun depersonalization, but as people get more and more down into the depths, the depersonalization kind of increases. So in looking at which factors lead to burnout, we found that residents who felt that they have inadequate time for their personal and family life were the most likely to be suffering from burnout. In fact, 64% of those who screened positive for burnout in our survey expressed that this was an issue for them. And for those residents who felt that they had inadequate time for their personal and family life, they were even more likely to be burned out if they felt like they had poor faculty support, had a large clerical burden during their work, and also had really long work weeks on the inpatient unit, which, while of course residency can be slightly different than attending physician life, this kind of parallels what the ADPM&R study found as well. And so while time for personal family life was the single most highly associated factor, unsurprisingly, there were a lot of different things that we found that were associated with burnout. I'm not going to go through all of these figures in the paper, as well as all the data, so we encourage you to go take a look at it, but I do want to highlight a few things. So in regards to demographic and personal factors, we found that female residents, as well as those who experienced mistreatment in residency, were more likely to be burned out. And then when we went into the program characteristics, residents who spent a greater proportion of their time, and we actually had asked specifically about rotations within the last six months in order to kind of get a more recent picture, but those who spent more time on inpatient rotations were more likely to be burned out, as well as if they had really long working hours during that time. It seemed that residency wellness programs that were structured were protected as well, and peer mentorship programs were also helpful in decreasing burnout. And one thing we found, it's not on here, but was interesting was that faculty mentoring programs did not seem to be associated with burnout. Just a couple other things to highlight. Again, the clerical tasks here were a big issue with residents in burnout. And also, as we talked about with the mission focus, if you're not doing what motivated you to choose PMR in the first place that can also lead to burnout. So in general our data suggests that there's lots of factors that are associated with burnout among PM&R residents and in particular feeling like you have that work-life balance seems to be extremely important and what we hope is that some of these findings will lead program directors and other leaders in academic medicine and who are responsible for trainees to find these to utilize these areas in order to target them for changes in their particular programs and hopefully that will help to decrease burnout among trainees. And now I will turn it back over to Dr. Capizzi. Okay all right thank you Dr. Bean. Let's go ahead and talk about women physician burnout. This is something I'm really passionate about and make sure I can control. There we go. So we talked about the problem of burnout focusing on the individual rather than the fact that this is a system issue but the thing about addressing this as a system issue is that we often ignore a really important physician population. There are a couple physician populations that I wanted to highlight. Women which now overall you know across all specialties women now are more more present in the medical field than men are as physicians not necessarily in PM&R but when you look at all physicians that's true. And then I wanted to make sure to discuss some of the issues that our underrepresented racial and ethnic groups face. So this may this also comes from the 2021 Medscape survey in terms of are women or men physicians more burned out and I realize this is binary gender determination but wanted to to drive home the point that overall women tend to report more burnout than men. And we talk about a number of things that could contribute to women physicians specifically experiencing more burnout. One being the gender pay gap, women taking on more citizenship tasks, women having more responsibilities in the home typically than men. But one thing that we tend to avoid talking about is debt and educational educational debt and financial stress. And I'm wanted to highlight a paper that we recently published in 2021 and this year that I had an opportunity to work on looking at physician compensation and educational debt and how that affects financial stress and burnout in women physiatrists. So this was a cross-sectional survey study of women physicians practicing in the United States, PM&R doctors. We had 245 respondents that met our inclusion criteria mostly meaning that they're attending physiatrists. So we did have trainees respond but we're focusing on attending physicians for this part of the study. Most of our respondents were early career so right out of their training up to 10 years of experience in practice although we did have some respond that were more advanced in their career. We saw that most people said that financial stress was related to higher burnout and when we asked people if they had ever had educational debt nearly all of them said yes and looking at the median amount of educational debt you can see here on the screen the median amount was about $100,000 to $150,000 whereas our maximum category was over $200,000. And most that responded to our survey reported they were still dealing with current educational debt. And breaking down our study further we did look at racial and ethnic considerations and we found that people who identify as black or African-American had higher levels of current educational debt and that burnout scores were significantly associated with higher current educational debt and lower compensation. So something I think really important for us to be aware of and certainly for our institutions to be aware of. So the key points from our talk are the following or from our paper are the following that debt is an underappreciated barrier to wellness among women physicians and women physiatrists in particular. That higher debt was associated with work-life dissatisfaction and burnout. Increased debt meant that people were more likely to respond that they would not want to become a physician again. There was a greater effect on people who identify as black or African-American and that higher debt and lower compensation is strongly associated with higher burnout scores. And as we're talking about a really heavy topic I don't want to avoid discussing suicide because we have lost members of our own community to suicide so it's worth bringing up for this conversation. And certainly an issue that impacts many different specialties as noted on this slide as this is national survey data and likely under reporting right because people are self-reporting their suicidal thoughts which is a sensitive topic. And that we lose about a doctor a day to suicide so almost you know an entire medical school class every year to suicide and the reason I wanted to bring to light the statistics and trainees on the screen here is that you know I think traditionally we've thought of burnout as being something associated with people who've been in practice for 30 years or 40 years and oh yeah well they've been working so long so of course they're experiencing these thoughts or these symptoms but it's actually happening earlier and I think that Dr. Bean did a fantastic job highlighting this issue of burnout in trainees and I wanted to touch on the fact that many of our trainees are experiencing suicidal thoughts. And here's the national suicide prevention line as well as a number of institutions and ACGME certainly has programs available for trainees that are are feeling those things. And now I'm going to hand over the talk to Dr. Yorks to talk about a lighter topic of exercise and wellness. Great thank you Dr. Capizzi. So certainly shifting gears a little bit naturally you know there's been a significant amount of research that's shown a positive correlation between increased physical activity and overall well-being so a natural question becomes can exercise be protective of burnout particularly in a very stressed population like a trainee or physician population. And we're going to explore let's see if I can switch the slide there we go. So we're going to explore two studies that that evaluate that very discussion. So the first was done by Dr. Verduzco Gutierrez and colleagues it was published in February of 2021 in BMJ Open Sport and Exercise Medicine and specifically was looking at active women physicians. So we had talked about the fact that literature has shown that women physicians have shown to have increased burnout compared to their male colleagues. So this is looking at burnout in a physically active sample of women to better understand contributors to burnout despite healthy exercise habits. So it was a cross-sectional electronic survey study and they used the American Medical Association's Mini-Z Burnout Survey. So they specifically recruited subjects from from a social media group of active women physicians so women runners and of the 1,000 active members of this group 382 completed the survey 369 were eligible and essentially they found that the median amount of exercise per week was five to six hours and over 60 percent of the respondents were getting over 10,000 steps per day. And the the data essentially what their main findings were I think is really well depicted in the image on the screen where on the y-axis is the Mini-Z score where a higher score is lower burnout and on the x-axis is number of hours worked per week and then you can see in the dots the gradation is amount of domestic responsibility reported and so essentially what they found is that there was increased burnout that was significantly associated with greater domestic responsibilities and greater hours working. So main takeaway from that study is that you know aerobic exercise alone may not control burnout and particularly when we're looking at a female population it may be important to consider addressing work-life integration as we're trying to target well-being. So a second study that we're going to look at is actually one that I conducted when I was in medical school. This was a 12-week non-randomized controlled survey study to evaluate the potential relationship between exercise stress and quality of life in a medical student population. So we had about 94 first and second year medical students who self-selected into one of three groups. The first group was a group exercise group so agreeing to participate in one to two group exercise classes per week. The second was a health enhancement group so participating in regular exercise but not group exercise and then the third group was a control group that didn't exercise and we specifically looked at perceived stress so how much you perceive situations in your life as stressful as well as mental physical and emotional quality of life. So we had 69 students who completed the study and at baseline there were no differences between the groups except perhaps as expected the fitness class group and health enhancement group participated in more exercise per week than the control group at baseline but there was no difference between amount of exercise between the two groups. On average those in the group fitness group participated in 1.5 group exercise classes per week and an average of 2.95 hours of exercise per week. The health enhancement group actually exercised more per week so 4.11 hours per week of exercise and the control group less than a half an hour of exercise per week and our main findings are depicted here in table three where you can see an improvement in perceived stress as well as physical mental and emotional quality of life that was statistically significant for those who participated in the group fitness classes. The only other group to show statistically significant differences was the health enhancement group which showed a improvement in mental quality of life and this was comparing week zero to week 12. So taken across all 12 weeks when we averaged the quality of life data the image on the right shows essentially an improvement in mental physical and emotional quality of life that favored the group fitness class group over the other two. So you know I certainly recognize that this study was not without its limitations. It was a small sample. It was non-randomized. I was the principal investigator and also taught all of the fitness classes and I also recognize that the actual change in score between week zero to week 12 while statistically significant was small so hard to tell you know statistical significance versus clinical significance. Though I can say this picture here is actually of me teaching at my medical school to a group of students and faculty and my classes averaged literally 70 people twice a week. So I think that that just speaks to the the need and the power for something along these lines or the power of community when we're talking about trying to improve well-being in in a particularly stressed population. So you know takeaway here exercise alone certainly may not be protective of stress and quality of life but I do like to think that the social supportive community aspects of potentially group exercise may have a protective quality. So with that I'm going to pass it off to Dr. Verduzco Gutierrez to talk a bit about the PM&R Wellness Initiative. I'm so honored to be working with my colleagues and mentees and presenting today, who've worked with me on some of these projects, and I will tell you that our major societies and organizations have come together, the ABPM&R, the AAPM&R and the AAP, and have decided that burnout in our field is a crisis and this is something that we do have to address. And they have put their both financial wallets behind it as well as time and leadership to say what can we do to look at burnout in our field. They've started already doing both qualitative and now quantitative research, and there's a big initiative to look at this. It is very unique as there's a longitudinal aspect of the study so some people will be followed over time to see what happens in our field. It has been already broadly distributed, so please, please, please take the survey. There was reminders today that went out again, reminders from the AAP, AAPM&R, you should have gotten one from Stanford. If you search in your inbox for hashtag PMR wellness, then you will see that there is the National Posiatrist Wellness Survey, we're trying to get many, many responses so we can really get a real pulse of what's happening in our field. The questions come from both, we're working with Tate Shannenfeld from Stanford, and his institute there, and we are looking at, that's why the interviews were initially done to see what are the issues that are mostly affecting physiatrists right now at all different levels. And so that you should have a link, you should have an email and just my job is to come back and say, we don't know all the answers, we know that it's a problem, and we know that there are many factors and we need to figure out what those are. I will tell you also, it's not going to take a bunch of your time, the median time is about 10 to 11 minutes, so when you do it, expect to take about 10 minutes, take those 10 minutes to do the survey and it will be a huge part in helping our field figure out what is contributing to burnout and hopefully have some answers for this as well. This is our information, all our emails, and you can find us on Twitter, and we're going to go back to Dr. Yorks. Yes, thank you so much. So, you know, with that, we certainly just presented a lot of data, a lot of different studies describing burnout, factors that contribute to burnout in a variety of groups, but really we think that the power of what the entire group that's here can offer would be really great to tap into, and that's what discussion with you all. So the way that we'd like for the discussion to run is if you all are able to put either questions or comments into the chat box, I'll then read them out, and then we can either address the questions or have further discussion. If you'd like to comment about a specific thread, a specific part of the discussion, you can use the raise hand feature if you're able to with Zoom would be really helpful, and we can call on you that way. So one thing that had come into the chat earlier is, are we all wearing matching outfits? And the answer is yes, we are. Fogucci. Part of the crew. So let's see. We can send, so someone is looking for what is the link for the study. Okay, thank you. Dr. I said that, please look at your junk box. I forgot to say that. Mine went to my junk box, so I had to go into my junk box, and I at least knew I was looking for it because I am part of the committee that's looking at this, but now, you know, look in the junk box and hashtag PMR wellness, and that's where you can find it. The other thing we're open to hear for the last, you know, time that we have is, you know, what people are doing. This is about, you know, what are, there's not great what's evidence-based. I think we're still learning that. That's one thing that's going to be looked at. That's part of the survey, where it's saying, you know, what is your practice setting, and is it academic or not? Are you employed by yourself? Are you, you know, are you private practice? What's your, you know, what's your practice setting? Are you employed by yourself? Are you, you know, are you private practice? What's your compensation model? So even though there's a question on compensation model, there's a question on debt as well, since we said this was an issue. There's demographic questions, too. Another question, is there any discussion about problem of excesses of capitalism within healthcare, pulling out resources that are needed for direct patient care, given excessive costs in US healthcare compared to other Western nations? Well, there's definitely questions about resources and how, like, resource utilization, and if you feel like you have enough resources for your care. Great. And we have somebody who chimed in that they have a, so in terms of what what's being done at other institutions, at the Carolinas Rehab, they have a resiliency curriculum of eight workshops per year, along with weekly mindfulness exercises. Are there any as, as we're shifting into what other programs have done or are doing, does anybody else want to chime in about anything you think has been particularly helpful at your own institutions? I like this, what Dr. Bell wrote. Working with residents on problem-solving treatments, often it's hard for them to step back and analyze what the causes of stress are, and if learned well, might have a long career impact. And if anybody also wants to unmute to be able to share, you know, a comment or something that's been particularly useful at your institutions, please feel free to do so. You know, I just want to comment. This is Kathy Bell. You know, it's hard to know where you go with this whole business of trying to build resiliency in people. Our 27, 28, 29, 30-year-old residents, they are who they are. And, you know, in terms of do they have resilient personalities or not, it's, it's hard to know. And then, oh, go ahead. Oh yeah, I was just gonna, looking at the chat box and trying to scroll through some people's comments that I thought this was a really good one from Dr. Brandenburg, are the residents burned out because the docs training them are, or are we turning our burned out residents that become our burned out staff, right? This is getting to the point that we've been speaking about with the trainee evidence, the trainee research that Dr. Bean discussed that we have duty hours for residents, but not necessarily for staff, but the trainees are still feeling burnout. So I don't know that the duty hours are necessarily the solution, but it's a good point. Yeah, I don't like, let's do more sessions for burnout when people already feel that they don't have time. That's kind of, I'd rather people have time hopefully doing what they love. I like this Dr. Alexander's UNC mantra, take care of yourself, then take care of your family, then take care of your colleagues so we can all take care of our patients. I think the discussion about, to Dr. Bell's point about building resilience or resilience in as a practicing physician, as a trainee is interesting because part of what we're seeing is it's not, it's not just at the individual level, being able to manage specific issues that come your way, but also at a larger systemic level, are we being challenged or pushed in ways or beyond that are then more than what we should necessarily have to overcome. So not necessarily just at the individual level, but also looking at the next level above and beyond that. Let's see, so a couple more comments from the chat. So my county medical association sponsored monthly dinners pre-COVID with about five to 10 other physicians in my area with some conversation starter questions. I really enjoyed an excuse to share and connect with other colleagues from other specialties. Sadly, the funding ended and then COVID hit so we haven't met since. So again, speaking to some of the community and the connection that's been identified as a potential mediator of wellness. And then Stacey Stibb agreeing with you, Dr. Rodriguez-Gutierrez, that when you're already burnt out, it's hard to find time to do additional sessions and learn how to deal with being burnt out and agreeing that the need to look at systems issues and it's not the physician's fault. I'm a really big fan of, you know, time together. Like if you have the time together, if you want the time together, or when you have to be in a work, in shared workspace. I was listening to a podcast, a recent really, I have to find it, the brain one, what's it called? I'll tell you, Hidden Brain. And there is one about connections. And it talked about when people officed kind of together in the same space, they really had this camaraderie and shared loyalty with each other. And then they moved half the people two floors up and they crossed each other in the hall and they realized like, oh, they didn't maybe have as close relationship as they thought, but just that time that they were together, it was kind of that shared experience. And so, I don't know, I think when I think back to residency and you have your colleagues, you know, if you have a decent sized residency program, you have your colleagues that are there, that you get close to the people who are physically close to you. So I can kind of think of other places where I office next to other people. And then by the time you're a chair, you just offer office by yourself. And so it's like more lonely, but maybe kind of more shared spaces. There was a good comment just a little while back about you need to find your own version of wellness. And a lot of times I feel like our system doesn't allow you to have your own wellness. It's like, you got to do a session to do wellness, but like, well, my session, my way of addressing my wellness may be different than the way someone else addresses their wellness. And I think the socialization part is a really good point. And I think maybe having more flexibility would be a great thing to introduce to institutions that certain people are people that could, you know, be eight to five people and certain people need to have a little more flexibility or, you know, that would address more than the burnout that would address women in medicine and people who have, you know, families to get to. So. We have, our Dean right now is working on an initiative of like give five minutes back. What can we do to make things more efficient to even give someone five minutes back a day? I don't know. We're kind of as a whole institute working on what can be done. A few comments have also come through about culture in general and kind of a sense of community, a sense of team. So a sense of team being highly important. There's always more energy when teamwork is present and maybe not necessarily just having the, you know, the doctor's dining room, but being able to bring all of our interdisciplinary team together and then a comment from one of our residents, Dr. Vail, that the experience, the shared experience and camaraderie is huge and honestly, a silver lining of COVID, their class grew together at work, especially when they couldn't travel, see families, et cetera, which is interesting. There's a question, if they looked at the effect of the amount or quality of the work that they were doing, if they looked at the effect of the amount or quality of maternity leave, they definitely have surveys where they look at vacation and if you don't take your vacation, you're more likely to be burned out and that there's, you know, high percentages of people who leave vacation hours and days on the table all the time. And there was another study where they looked at then what you did on vacations, because maybe you go on vacation and all you do is answer your phone and respond to emails and just continue to work all the time and that women are really, really bad about that, especially, and that can factor into burnout too. So when you take a vacation, I really encourage people, you know, put an outbox message, say that you're not gonna respond to messages and really guard your time. Yeah, and then some of it is also, we need to really work on shifting mindsets about what is strength and what is priorities. And that's part of, it's culture and where you are. You have to ask about the culture, where you're gonna be and, you know, what is respected and, you know, realizing when it's time to lean in and when it's time to lean out. And I heard something the other day that almost made me cry when I heard it. It said, your children don't read your CV. You know, they don't care about what is on your CV. They want you there. This is probably coming from somewhere. Her children think that she's not there enough. So, you know, even I need to. I like the comments that you made, Dr. Virgis Cogutieres, about taking your vacation time. And there's a comment from one of our trainees at Stanford that's, you know, mentioning that a lot of us, when we're in training, are required to use vacation for these academic things, like we have to get into a fellowship or we have to get a job. And that that's something that could be changed at a system level that trainees don't need to use their vacation time to specifically, you know, do things like try and get a job, which they need. And to your point, Dr. Virgis Cogutieres, Sabrina Young had a comment here also saying that, you know, essentially how we prioritize family can be seen as a sign of weakness or not being serious about training or career. And these are some of the bigger systems level cultural ideologies, I think that need to be broken down a little bit. I know we have four really, you know, powerful women on this panel who, you know, have significant others or families, but also are very serious about their careers. And I think we're generally moving more towards that direction, but still certainly have a ways to go. The other thing is system level changes go far. I, when I was in Houston, did two different burnout projects with our residents. One was where I had them, you know, we did storytelling and we worked on, you know, more kind of insightfulness and storytelling on how things were going or with experiences. And it wasn't a forced thing, but we learned that people who weren't doing anything before continued not to do anything. So they didn't want to do this either, even if they weren't exercising or doing their own wellness thing. And it wasn't like, no one's burnout really changed before and after. So just kind of the bigger lesson was like, people are going to do what they're going to want to do. And if they already do stuff for themselves, they're going to do it. But then when we did another project with some of my prior trainees, like Jason Edwards, I don't know if he's here or not, but I know he was presenting something earlier. And we did with admissions, when the late night admissions, with admissions, when the late night admissions came for the residents, they just had to write holding notes in the next team in the next morning and do the admission orders. And the next team in the next morning had to do the full HMPs. And we looked at time back that they got, and they got at least an hour back per night for each admission that they got to do a holding note. And it really also decreased their stress and decreased their burnout. So that was something bigger at a work hour level. And no patient was hurt in this. They were still assessed. They were still seen. Their note was still done. No roles were broken, but it contributed a lot to resident satisfaction. A few other great comments that came through, kind of, again, highlighting the study that was done on debt and financial wellness from one of our trainees, that often what goes unadjusted, the amount of time that we spend in training that then delays other parts of our lives. And then, you know, starting your career in your mid thirties and then adding debt on top of that is a really interesting comment. Yeah. Yeah, when I took a healthcare management course as a fellow, they talked about, they likened physicians to football players, that we are, you know, relatively high earners, but we do it in a short period of time because we don't get to start making money until we're much older. And they talked about how football players tend to retire bankrupt. So don't let that happen to us. But just the takeaway being that it is a lot of, I mean, even though we're making more money, we have a high amount of debt burden to address and it's kind of becoming overwhelming. That's one thing that when I'm at big, you know, I'm on the board at AAP and I talk about that, when we talk about just like the debt burden, it's so much more for new graduates than it was even when I was a graduate and it's crippling. You know, people less likely to choose certain specialties or certain subspecialties because of worries of how much money they have to make, even, you know, choose to go into academics or not go into academics because again, financial stressors. Yeah, we found that as a trend in our debt compensation study, that people with more debt were less likely to be academicians, you know, less likely to be, you know, going into fields where they were mentoring because perhaps because of that debt burden. A few comments that have popped up about having coverage or inadequate coverage and that's really true is that, you know, when the burden falls on colleagues who already have a significant workload that we're all here to take the best care of our patients possible and somebody has to be there to take care of the patients can add just an additional level of stress. Right, it's hard if you're in private practice, then you also have to worry about your own. If you don't work, you don't get paid. I'm horrible at typing, it's Rita Hamilton. I'm just chiming in with what Kathy Bell said. You know, we looked at this years ago in our group and what we did, we hired what's called a rotator. So this person goes from every inpatient facility that we have and they cover so people can have time off and we have made our team and say, I will take time off every quarter. And so it covers the rotator salary and it gives our docs time off and it doesn't put extra stress on faculty when you take time off. So it's been a wonderful addition to our attendings lifestyle, if you want to call it that, it's been very helpful. Sometimes, not taking time off because there'll be more work for you when you turn. Yeah, that's why I say when no good deed goes unpunished. If I try to go on vacation, they just give me double clinic the next week, 10 more meetings. But then you have to like, yeah, say no, no, it's a sentence, a full sentence. Say no to your chair, you can. If you, a few suggestions, should we do the, you know, should we do this type of session again next year that it may be interesting to do breakout rooms? Hopefully we'll be in person when we do this again next year, but perhaps small groups and certainly, you know, would it help to have these discussions with men colleagues in the room? So. Hopefully there's men in the room, but there's a comment there that talked about, yeah, system standpoint, healthcare benefits for family planning, for fertility services that is not talked about enough at all. And I would say there is only 12 states in the US where IVF is covered. And so then you have to look at, yeah, we should be advocating for those kinds of services and support. Right. Family leave, you know, really important among trainees as well as faculty. Yeah. Yeah, I hope it's a big session next year. I think that, you know, it'd be great, big session to have like something with breakout rooms or something that's, you know, given a lot of attention. This has been really wonderful to see how many people have popped onto this session and contributed in the chat. We have just about like five more minutes here. If there are other comments that anybody wants to make, again, you can feel free to unmute yourself or put it in the chat would be totally fine. Putting some of our papers in the chat. That's great. Thank you. Yes. And from the chat, I think this has been so beneficial just to know that physicians are not alone in these feelings. I'm the only female in my practice, the only subspecialist, the only one with school-aged children. It's a tricky dynamic to care for your patients as your own, as well as your own. Yes. One thing that's helped me immensely was at my quarterly meeting with my boss, I was asked to list the five things that would make my job better or easier. And then he addressed most of them. I do have, you know, we have to do annual reviews with our faculty. So I do make them stay interviews is what I call them. And, you know, where I'm asking about, you know, what are their pain points? And I really want to know what the pain points are and how I can help with that and what they feel still is a benefit about being in the department. Then of course, talking about their goals for the next year, but it's also realization that sometimes the pain points may not be something that everyone that can be met, especially if it has to do with a lot of, you know, getting a very large salary that can always be met in academia, which is sometimes a pressure that people have, going back to the debt that I've seen in real life, you know, real life with my own faculty members and what kind of stress that puts on people. So there's only so much for now that can be done. But it also means a lot to hear that, you know, someone who's above wants to know what issues and what can be done to address those. Because some stuff can be easily addressed. And it's also the culture and the people around you. Do you want ones that are going to, you know, if you have a family emergency, they're just going to step in and help. An interesting comment that had been made, I believe it was at the AAPMNR conference last year, was that it's interesting how because of COVID-19, you know, and so much of what we do being shifted to telemedicine and over virtual, over Zoom, that this has actually allowed for a little bit more flexibility that's been acceptable almost. And that might be something that's almost a bit of a silver lining, which I think was just an interesting comment that was made last year that I still think about. The job share. Let's see. One thing that has helped my practice partner and I is doing, yeah, job share. Rotate every few weeks. Yeah, in academics, there are lectures as part of the education that you have to do, but it doesn't always make a big dent on the CV you're on promotion. So then it's like turning those lectures into what can go onto my CV. Who can I collaborate with? What can be, yeah. Or making in your own, making the department have that be worth RBUs, you know, eRBUs, educational RBUs, so that maybe you're not making 100% of your goal, but you gave 20 lectures, that's equal to a certain amount of RBUs for times that you put into it. So it's for something. And I know we're coming up on the end of our conversation, but there's one I wanted to highlight is this idea, again, of like work flexibility. And one person commented that, and one person commented about rotating, like them and a partner sharing their job tasks so that, you know, you're on for a period of time, you're off for a period of time, and it's just baked into your schedule rather than having to take dedicated time off. And it's certainly something that a lot of other specialties have implemented, like hospitalist medicine, neuroservices, neuro ICU, do a lot of things like that. So that's a great point. Great. So with that, I think this is going to be the end of our session here. It's going to close in one minute, but on behalf of the team and myself, thank you all so much for joining on to be a part of this presentation today. We genuinely appreciate you taking the time and being here and sharing so much and making it such a valuable discussion. So enjoy the rest of the conference and we thank you. Bye.

burnout in PM&R

systemic perspective

trainees' burnout

inadequate personal time

poor faculty support

burnout in women physicians

financial stress

exercise and wellness

PM&R Wellness Project