Okay, just for the sake of respecting everybody's time this evening, I'll go ahead and get started. So I'm Elise McClanahan, I am the co-chair of the early career physiatry member community along with Dr. Elizabeth Martin. And we are going to talk a little bit today about burnout in early career physiatrists kind of with a panel discussion, so I've got a little bit of a talk just about burnout overall. I was researching this, found a lot of this really interesting, so hopefully you will too. And then we can have some more open discussion on burnout, along with our guest who is the wellness champion for the Department of PM&R at Vanderbilt, which is Dr. CJ Plummer. So our session objectives are going to be to discuss, pretty straightforward, to discuss burnout in physicians, including burnout in different career stages and within PM&R. And then really the kind of the meat of the evening is our panel discussion on burnout with questions and answers. So when we were considering topics for this Member May session, we did a poll for the members of the early career physiatry community, and one of the top concerns noted among members was burnout, which is a growing concern in the field of medicine in general. On the most basic level, when you type physician burnout in the search field on PubMed, you get over 7,000 results for different articles. So this is obviously a topic that garners a lot of attention and has a lot of room for discussion. So I want to take a few minutes to discuss burnout in general. First of all, how is burnout defined is actually included in the 11th revision of the International Classification of Diseases, the ICD-11, but is classified as an occupational phenomenon and not a true medical condition. So per the ICD-11, burnout is defined as follows. Burnout is a syndrome conceptualized as resulting from chronic workplace stress that is not successfully managed, is characterized by three dimensions, which are feelings of energy depletion or exhaustion, increased mental distance from one's job, or feelings of negativism and cynicism related to one's job, and reduced professional efficacy. So it refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life. So it's interesting, burnout was described in ICD-10, but it's had a lot more detail in the ICD-11. So one thing I think that gets talked about a lot is the consequences of burnout. So in terms of patient care, you see lower care quality, more medical errors, longer recovery times, and overall lower patient satisfaction. For the physicians, more issues with substance abuse and mental health concerns, depression, suicidal ideation. There was a very public or very well-known physician suicide toward the beginning of the pandemic that I think brought a lot more light onto this as well. Poor self-care and then motor vehicle crashes. And then at the system level, worry about decreased productivity and increased physician turnover, which would result in less patient access and overall increased cost. So burnout in medicine, there's been a discussion about burnout in medicine for some time, but it took on an even greater prominence with the COVID-19 pandemic. The AMA has been working to address burnout and published results from a survey conducted among the AMA, Mayo Clinic, and Stanford Medicine showing that 62.8 percent of physicians experienced burnout in 2021, which was a substantial increase compared to prior years. Other studies have indicated that one in five physicians plan to leave clinical practice within two years and a third of physicians anticipated cutting down their hours. So factors identified by the AMA as contributing to burnout. Have included ones at systems and societal levels, more specifically, they have noted increasing administrative burdens and hassles, inadequate support and practices and systems to help address those burdens, deliberate disinformation campaigns and political attacks on medical science and third party interference in the patient physician relationship, namely like kind of dealing with insurance and other third party providers. So burnout in early career, so the AAMC actually had a very interesting study about burnout and depression where they looked at medical students, trainees, so like residents and fellows and then early career physicians looking at burnout and depression. So there were high rates of burnout, depression and fatigue in all three groups and there were symptoms of all three, so depression, burnout and fatigue reported in 40 to 50 percent of early career physicians. There was a similar study looking at burnout among physicians across the career continuum. This showed that mid-career physicians had some of the highest levels of burnout, but there was also an alarming trend among the early career physicians. Most notably, they had the lowest rates of satisfaction with their overall career choice, i.e. being a doctor, the highest frequency of work and home conflicts and the highest rates of depersonalization. So then if you move next kind of to burnout within PM&R in general, there is one group that's been looking at the rates of burnout among different medical specialties every three years starting in 2011. So this table, small is probably kind of hard to see, summarizes the percentages of physicians in each of these subspecialties that suffer from burnout and how they rank. So PM&R is here on the chart, the yellow arrow kind of shows you where we fall. So in 2011, PM&R had the 10th highest burnout prevalence and in subsequent years that has risen. It reached its peak in 2014, where it had the third highest rate or prevalence of burnout among medical specialties, followed by the fifth highest in 2017 and the seventh highest in 2020. So there was a collaborative effort between the ABPM&R, AAPM&R and AAP, and that's part of one of the Academy's initiatives to address burnout. They conducted a study to identify factors contributing to professional fulfillment and burnout in PM&R physicians, as well as the variability in experiences of burnout fulfillment among different specialties. So overall, over half, about 55.2% of physiatrists experience work exhaustion, while 35% experience interpersonal disengagement. 46.2% experience overall burnout, so almost half, and only 30.6% of physiatrists reported high levels of professional fulfillment. So when they looked at the different kind of or different spectrum of PM&R, the different areas, they kind of focused on acute care slash inpatient rehab, outpatient settings, and then subacute rehab facilities. So looking at factors that predicted higher levels of professional fulfillment on the more acute care slash inpatient rehab side, and those included teamwork and collaboration and finding meaning in your work. And the outpatient setting, like alignment of personal and professional values, predicted higher levels of professional fulfillment. And then in the more subacute setting, they noted that control over schedule and optimal integration of physiatry into clinical care helped to predict higher levels of fulfillment. So what kind of response has there been? When considering all of these different things that we've talked about, there seems to be a lot of systemic issues. So the concerns about burnout have made it to the highest levels of government. In 2022, the U.S. Surgeon General, Dr. Vivek Murthy, published an advisory addressing health care worker burnout. It is quite long. I believe it was over 70 pages. But the key takeaways from the advisory included the causes of burnout. So this was in this report attributed to workplace systems with a range of societal, cultural, structural and organizational factors, including excessive workload, administrative burdens, limited say in scheduling and lack of organizational support. They also noted issues with workforce shortages, and it is anticipated that physician demand is going to continue to outpace supply, leading to an estimated shortage of physicians anywhere between roughly 54,000 to 139,000 by 2023, which is nine years from now. So it is anticipated that the gaps will be most significant in primary care and rural communities. They also noted the differential impacts on health workers, so burnout, resource shortages and high risk for severe COVID-19, because again, this was being studied more in the height of the pandemic, unevenly impacted women and health workers of color due to pre-existing inequities around social determinants of health, which ultimately were exacerbated by the pandemic. And then the final of the key takeaways was that health care worker burnout harms everybody. So if unaddressed, the burnout crisis will make it harder for patients to get care when they need it, cause health care costs to rise, hinder the ability of medicine, the medical community to prepare for a future public health crisis, and overall worsen health care disparities. So at the PM&R level, there was a formation of a tri-organizational workgroup, so AAPMNR, ABPMNR and AAP, to study and work to address the issue of burnout. So that was where that workgroup helped to form the results of that one study I've already mentioned. AAPMNR has had multiple advocacy initiatives that they've noted, including reforms with prior authorization, advocating for IRF review choice demonstration, and then removal of the post-admission physician evaluation. And then also one thing you can note, they've worked on changing the maintenance of certification requirements to reduce the overall physician burden. So I'm sure one of the biggest questions for this is what can we do? I found this quote from Dr. Amy Houtrow, well known in our field, and thought it was worth sharing that health care workers are in a double bind that no amount of baby goat yoga will fix. And she was referring to kind of the cultural thoughts or the cultural presentations that sometimes burnout is related more to lack of resiliency or it feels like it's more personal when there are also a lot of systems issues that contribute. So we only did one slide on this, because I think we're going to talk a lot more about this, and it also comes down to a lot of these things are things you will find in almost any resource. But this particular list I included because it was produced in a paper that there's one workgroup that's done a lot of work with burnout. I think it's published through the Mayo Clinic Proceedings or several of theirs are. And they came up with this long table of kind of system and individual things. And this is what they noted for the individual strategies. So kind of divided it a little bit into workload and clinical responsibilities. So talking about do people want to go down to part time status, having more informed specialty and practice choices, training for skills and efficiency with EMR and overall efficiency with practice, and then delegation of tasks, whereas looking at work-life balance, kind of internal conflict, considering stress management, resiliency training, mindfulness, attention to self-care, and then kind of looking at how you prioritize your work-life balance. So, like I said, that was just a very brief presentation. And we wanted to spend the bulk of this time going to be able to talk about burnout, kind of see where people are and have a chance to discuss. So with us for the panel, again, it's me, this is Mary Ann Harriman, Lisa McClanahan, and then Dr. Elizabeth Martin. We are both pediatric physiatrists at Vanderbilt and are the co-chairs for the Early Career Membership Community. And then we have invited Dr. CJ Plummer. He is the wellness champion for the Department of Physical Medicine and Rehabilitation at Vanderbilt and has done a lot of work and can try to promote wellness within our department, probably also in his work at the medical school. So we definitely have some questions that we want to discuss. And then we also want to hear from you guys so we can monitor the chat. Feel free to jump in whenever you have a question, because we do want this to be an open, a chance for a more open forum as well. And I was, you know, what I would I'll say just to maybe help kind of jumpstart things a little bit. So, yes, thank you for that introduction. I had the pleasure of working with these two fine physicians, and I really appreciate all the work that they've done in our department on this topic. Just to give a little background on me, so, yeah, as she said, I'm our V-Well champion here. So what what that means is, you know, Vanderbilt has we all are at Vanderbilt. What the administration at Vanderbilt has done is they've tried to have each department have a wellness champion, and that's what this V-Well status is. And so this is someone who, you know, is a clinician and is there to advocate on behalf of faculty in terms of, you know, in terms of physician or really just provider wellness period. And we also have nurse practitioners in our practice. And so that is that that is kind of the scope of that role. I've also, you know, as of this academic year, been involved at the School of Medicine through a faculty college mentor position where we work with students from the first day they start medical school until the day they graduate. And it involves professional development, wellness, but then also where small group facilitators for their it's kind of like they're learning communities or their longitudinal course on medical humanities and professional development. So I've had, you know, I've had some time to really think through and to experience a few things in terms of this topic. And I'm really happy we're spending some time chatting about it. We just wanted to give that context behind, you know, my my involvement. Thanks so much, CJ, so if I can start off with a question for you, that's OK. Sure, absolutely. So one of the things that I think frustrates me a lot when we try to tackle this question is that it seems like a lot of these are they're trying to help us find ways to manage ourselves personally to cope with this larger system problem because we haven't figured out a way to fix this bigger system problem. And I think especially as an individual or as an individual who's very early in their career, I can feel like you don't have the power to do much to make a lot of change in that situation. So I'm just wondering if you have any suggestions or strategies, ways that people, especially early in their career, can try to get involved or feel like they do get some power in trying to make those bigger system changes. Yeah, absolutely. It's a great question and it's it's a multifaceted question, in my opinion. You know, as you stated, the challenges there can sometimes and I don't know if anyone on the call has felt this way, but there are times when it almost feels like there's this complete disconnect between between leadership, whatever at whatever level you were thinking about, whether it's kind of within the department or the greater leadership amongst an academic facility or if it's a partner in a private practice. There seems to be a big disconnect a lot of times between, you know, their ideas of wellness and then, you know, the sort of boots on the ground, we're in the trenches every day, sort of, you know, trying to get folks seen and trying to take care of folks and keep this balance. And so it becomes really difficult, especially as you as you said, Elizabeth, like you're starting and you don't really know. So in terms of strategies, I actually I would even take it a step further back, you know, and I'll contact I'll put some context behind this strategy that I'm kind of going to talk about, which is, you know, a lot of times when you really think about what we had to do to match to get into medical school and to match into a residency and then to match into a fellowship for those who did a fellowship, you know, we have to do a lot of selling like, you know, oh, I'm great. Pick me, pick me, pick me, you know, look at me, look at me. And a lot of times, especially at least in my experience and as I've talked to other folks within the early career space, we approach the job the same way out of training a lot of times where it's pick me, pick me, pick me. So what that fosters is this sort of, you feel even less empowered to advocate for yourself. You feel less empowered to sort of ask those questions on the front end as you're interviewing with places to really flush out sort of like what the expectation is, what the infrastructure is, what the support is for clinicians. And so I think that's a huge, and I made that mistake, you know, at least in my experience, a lot of folks that I've talked to have kind of felt similar in terms of that, because it's different when you become an attendee. You are now really, you know, the way it really should happen is, you know, you kind of present your interest, they present their need, and you kind of do this mixing and matching effect where, you know, you're probably not gonna be able to get every single thing on your list on what you want, but, you know, that's where some negotiation comes in based on what you're prioritizing, whether it's money or it's office space, or it's time off or part-time status, like Elise was mentioning, or, you know, whatever it may be. And so I think some work can be done, and this is stuff I wish someone would have told me kind of as I was transitioning out of training. Yeah, you wanna present your best self, but at the same time, this is really important to really make sure you understand what you're getting into. And so I would start there, but, you know, a lot of us have made the mistake and, you know, whatever, we're here now, right? And so kind of what we can do after we sort of transition and are trying to figure it out now, you know, I would say that the tricky thing is also that there's this balance you have to strike between, again, helping to facilitate the needs of a department, but not at your own expense. And so I feel like that balance is what's really tricky. You know, certainly we all came into this profession wanting to be team players, you know, supporting each other, covering for each other, doing what we need to to get everything done, but it can come at a detriment to our own mental health, physical health, when we're doing too much of that and prioritizing a department or a system over our own wellbeing. And so I have, you know, done different things. I've spent a lot of time thinking about what it is I want and really trying to have that conversation with my leadership, my immediate leadership, which is my chair, as I've progressed. You know, the things that I prioritized when I first started changed, you know, two or three years into being an attendee. Life happened, you know, my child dealt with some illness, things back in the fall that really shifted things and we had to move pieces and reprioritize. And so, you know, it requires a continuous conversation with leadership so that they know where you are and you can know where they are. And then that really helps them dictate the conversation in terms of, are the things that they're asking me for reasonable? And if the answer to that question is yes, then, you know, you do what you can to optimize some of the personalized systems things, workflow things that we all hear about constantly. But if it's systems issues that you really can't work through, then, you know, it may be time to look elsewhere and then take the next step knowing that, you know, in the next job, you're gonna have a different approach in terms of what you're looking for. I've said a lot there. I mean, I wanna continue, kind of have everyone jump in a little bit, but those are just some preliminary thoughts and I'm sure I'll think of things as we talk some more. Looks like there's some things in the chat. There's some good questions. I just wanted to add too, I remember when I was looking for my, I think it was my first or my second job out and I was doing this exercise about what are my core values as I was trying to decide what it is that I really wanna do? Like, what are those essential things that truly need to be in my job for me to be happy? And then what are all those optional things on the side? And I feel like that's something that's important both as you're looking at your career, but also like once you're in it, are you still staying on track with those things? Is it still meeting those core values or are you starting to get sidetracked with your productivity or something else is distracting you from the things that are truly essential to you? And if that's the case, maybe you need to reevaluate. And like you said, maybe choose a different choice because we are a valuable profession and we have lots of choices. So great questions coming in. So first one, I'm becoming an attending soon, I've received the advice, say yes to everything upon starting a new position quite a few times, which seems like a bold strategy to take. I'm curious what your thoughts are on this. I sense there is a feeling of needing it to show employers who are invaluable right off the bat. What is the strategy to sidestep falling into that pressure? It's a great question. It's a fantastic question. I can take a stab at it and then, so yes, I think that's probably a majority of us. I definitely started here at Vanderbilt, this is the only place I've been in attending and wanted to just come out the gate swinging, just yes to everything, show value, prove value, prove that they didn't make a mistake in hiring me and all of the things that we do, kind of seeking that external validation on, cause we're used to the feedback we get in training as residents and fellows and we wanna be told we're doing a great job. And it just is not sustainable. Many times what that leads to, and I did just this, like try to say yes anytime someone presented something to me and pretty quickly I realized that it's just not sustainable. I started, it was kind of that idea of, and I'm sure there's a more eloquent way to say this, but it's kind of that idea of you're doing a million things but not doing any of them well. That's kind of where I kind of started being just in my journey. And so, I would say in terms of ways to sidestep the pressure, because it's significant, especially when it's your first job. I think you have to kind of, the balance again that I'm speaking to, I think you have to sort of challenge yourself to, well, let me back up. First, I would say, do not say yes to everything. That's just my opinion. I don't think that's a good strategy. I heard that strategy as well. And it really doesn't work. I mean, I think what's gonna lead you to make the most meaningful impact is saying yes to things that you're actually interested in, but then also giving yourself time to figure things out first, especially as a new attending. Someone told me it takes about two years to get your footing as a new attending. And I thought that felt kind of long. I'm like, why would it take two years to figure things out? But as I'm approaching being five years out, I completely understand that statement, because there are just so many factors. And then it's sort of a moving target. The goalpost is moving as the department needs change, and then family happens, and then it's all of the things. So I would say really trying to challenge yourself, not to sign up for everything, not to feel like you need that external validation, because what really needs to happen is a stepwise approach up to responsibility and into things that you're involved with. Easier said than done, for sure. But I think that framework has to be there where you're more interested in the long game than the short game of trying to impress really quickly. That's just my opinion on that. I think it speaks also to sort of the headspace that we're in after going through medical training, where we've been trying to prove that we're good enough for things for so long. And then we go into our first employment or whatever it may be, second, third, of now we've got to prove ourselves yet again. And I think really trying to take a step back and recognize our self-worth and what we're contributing to everything is really important. I mean, sure, you don't want your head to get too big and you need to actually do your job, but at the same time, trying to find those moments where you can really recognize like here are the things I'm contributing and maybe doing that for your peers too. And being like, thank you for doing this, this really made a difference and acknowledging that can be helpful. There's been a lot of work, I think, on self-empowerment recently. One of my colleagues sent me a podcast that's on empowering women physicians. And I don't think it's applicable just to women physicians, but I think it's a really necessary thing in healthcare, maybe even more than some other fields, because I do think we just spent so many years of trying to prove ourselves. And then it's kind of hard to make that shift then once you're in attending to being like, well, we're adults now, we don't have to keep proving ourselves. We've really done this and we really are valuable. And now we can do our job and do a good job at it, but we can also recognize what we need and take time for that too. It can be really uncomfortable to say no, like at first. I mean, I feel like, again, coming from training and everything that is very hard, but I definitely agree with CJ, we're kind of trying to, or both of you, we're trying to really focus on what you're passionate about and what you want to build your career around. And I think people are more understanding of that in the moment than we give them credit for when you're trying to actually say, hey, I just can't take this on right now. That speaks to where you are too. I mean, because if you're in a setting where they are not supporting that at all, you're probably in the wrong place. And again, it goes back to your values about what's important to you. And maybe you need to be in a certain location for family reasons or something. But one of my core values is being in a place where I respect and trust and really enjoy the people that I'm working with. And I want people who are going to recognize that that's important for all of us and support that. Yeah. You may want to prove you're invaluable to them, but they also do need you. So that's one thing I've started to really think about is like, they also, you know. And I think there are little things that you can do both to help yourself as you're starting practice to sort of check the boxes of like, here's all the stuff I'm doing to remind yourself, but also to use as you're like talking about promotion and such, and again, show your employer what you are doing. So being familiar with strategies to show your productivity, show what you're generating out there. So it's not just what they're telling you. If you're doing things academically, and again, you're probably updating your CV regularly and showing all these great lectures or whatever that you're doing. And having those moments where you're putting that all together and being, you know, reflecting on that can be a great time to both acknowledge that to yourself. But again, remember that you already are showing your value. Absolutely. I can't reiterate the importance of what you just said enough. I mean, it's, you know, you really want to leverage what you can. And many times you could be approached about metrics or number of patients or RVUs. And sometimes I've actually had it where some of that information was not actually accurate. And, you know, nobody knows that until you're having an open conversation. And you're saying, well, wait a minute, that doesn't make sense based on how many patients I know that I've been seeing in clinic or how many patients I know I've been admitting on the inpatient service. And so I would really, one way you can advocate for yourself is, you know, find, you know, I mean, it doesn't need to be confrontational, but just finding respectful ways to just sort of inquire about the metrics and the information being presented to you, how it was collected, sort of what sort of parameters were in place. Because that has been something that has definitely come up, you know, quite a bit. And that helps you then make the arguments for the things that are important for your work-life balance, right? Because then you can say, here's the things I'm contributing. Now, here's the time that I need for myself, or here's, you know, the hours that I need to set because this is what I'm generating for the system. But I don't want to get in the cycle of, well, now do more, do more, do more, which I think is where people get really disempowered and start to feel like everything is just too much for them. And that's where we definitely don't want to get to. Absolutely. So there's another tough one here. So I've been using the CFTAR, so Circumstance, Thoughts, Feelings, Action, Results model. So that's an interesting one. Throughout my medical journey, when I face a challenging moment individually, as an early career physiatrist and leader of our interdisciplinary team, how can we support our interdisciplinary team and ourselves who are facing moral injury, burnout around a poor patient outcome where the interdisciplinary team invested so much with an outcome that was out of our control and makes the team cautious around future patients with similar diagnosis and socioeconomic status that reduces access to care? That's definitely something you come across in PM&R and that's a tough one. Absolutely. Yeah, that's a fantastic question. And I really liked the first part with the sort of the acronym. I may have to actually start using that myself because I think that's a really good systematic way to approach things. I apologize. You may hear my family in the background. I have, speaking of wellness, I have an eight-year-old boy and a five-year-old girl and it's a school night, so we're running around trying to get everyone taken care of. But yeah, so to go back to the question, I think that's a good question. When it comes to supporting interdisciplinary teams, I think it can be very, that's tough. I'll tell you the way that it presents for me. The way that it presents for me is when I started at Vanderbilt, I do half and half inpatient, outpatient. And when I'm on inpatient, we actually get quite a bit of neuro-oncology patients. So these are folks who have had tumor resections after diagnosis of astrocytoma, glioblastoma, lots of kind of different things that can really come with pretty poor prognosis. And so I remember it being, it's funny that y'all asked this question. I remember it being, I remember it being something that I really struggled with when I first started, because for me, I just didn't anticipate it. I'd come out of training. I did brain injury medicine as a subspecialty and was really expecting to kind of start with a lot of our traumatic brain injury patients and didn't anticipate how much need there was around the neuro-onc here at Vanderbilt. Well, we had some poor outcomes. Folks who came to us very sick and a lot of the focus was more maintenance therapy than, I mean, certainly our goal is always to improve FIM scores or GG scores or whatever they're calling them nowadays. But it takes a different sort of part of your brain to think through the maintenance side of things. And we had several that just had a poor outcome and it was something that I just didn't, I think it really kind of hits you different when you're in attending and this happens. I certainly took care of patients who had poor outcomes as resident, but it just was different once I was in attending and felt responsible over their care. And so in the immediate, we did things like debriefing as a team. And so if there were, let's say there was acute care transfer, something really major happened suddenly, we'd get the patient taken care of. And then afterwards, I'd take some time to try to circle back with the members of the team, whether it was residents, medical students we had, some of the therapists, even some of the nurses and just debrief. And I had people model that very well for me as a trainee and it really helped me then implement it when I was in attending. Another thing that I utilized pretty early was the EAP service, which was kind of our kind of wellness or professional coaching. You meet with a psychologist or a counselor to kind of work through difficult times. And it doesn't just have to be related to patient care. It can be things going on in your own personal life. And so that was another thing, within probably within three or four months of me starting as an attending, I utilized those services because I had a few really, just unexpected sort of things happen for some patients who were doing well and then suddenly they weren't. So those are just some things. And then I also just tried to just sort of establish reasonable expectations because so many of our patients we take care of are very, very sick before they even get to us. And so it's giving yourself some grace. I guess it's more of a personal sort of thing that I thought through, but giving yourself some grace as you're recuperating from that event, because you probably did the best that you could. And folks are, you can't anticipate everything that's gonna happen. And I think that's a really important statement for you and also for the team. And Dinesh, I mean, feel free to speak up too if you wanna share your experience with this and what you did in that circumstance. I mean, I think acknowledgement as a team, making sure you still feel as a team because in PM&R we're the team leaders, but making sure the whole team has a moment to like stop and acknowledge that this was a really challenging circumstance and everybody really gave it their all and it didn't turn out the way that you wanted it to is important. And maybe like CJ was saying, like time to share and discuss and debrief is really important because we don't want it to affect our future performance. We don't want it to affect us to a point where we're sort of spiraling downwards and we wanna be able to give it our all to the next patient too. So I think, like you said, giving yourself grace, giving your team grace, acknowledging that everybody has that opportunity and that it's a really hard circumstance and we can't change everything, but we still keep trying to do our best is important because it's as hard as that is, it's also I think what makes us PM&R and why we do such great things because we really do try so hard in a multidisciplinary way to make a difference for patients. So I guess I'll, oh, yep. Thanks, Dinesh. Yeah, so it's debriefs and meeting individually. Yeah, and again, I think helping people know that they're not alone through that is important because I think when people feel like they're suffering alone, it just makes it that much more difficult and it can start to affect the team in a way that we don't feel like we're a team anymore. And we need to have that support of each other to continue to build on what we're doing and to continue to operate at our best. And we don't want our team members to suffer. Absolutely. You know, this actually kind of reminds me of something that happened today, kind of speaking to some of the community building. I picked my son up and, you know, he's eight and he's getting older and he's, you know, testing boundaries a little bit. And so he said something he wasn't supposed to in the classroom and the teacher told me and he was pretty upset about it and still a little upset about it. And as we were leaving, I ran into another parent, another good friend of mine, and he has a son, my son's name is Julius, in Julius's classroom. And, you know, our kids were in the car, so we just had this quick moment together in the parking lot. And we just kind of talked about, you know, some of the challenges with parenting at this age group, you know, and just learning on the fly and trying to figure it out. And, you know, I left the meeting with his teacher, you know, a little disappointed and frustrated, but then I also felt like, okay, well, I'm not in this alone after speaking with him. And I would say that that's something that I would recommend implementing even within our medical practice as well. You know, as things come up, don't be shy about sharing it with others because you'll find that as you share with others, that they're actually dealing with very similar things or have already dealt with very similar things. And, you know, I talk to our medical students a lot about this. You know, there's really a lot of benefit in establishing a community that you can lean into, you know, as you're kind of going through challenging times and transitions and all the things that we go through. So just another thing to sort of put on everyone's radar. Yeah, it reminds me. So the American Academy of Family Physicians has their own statement on burnout. And they had sort of three key points was, and the first one is that you're not alone, that knowing that others experiencing the same emotions can be reassuring. And that's true for so many scenarios, just like the ones you're describing here. The second was that you are not to blame, the system's to blame, and that you're not powerless, that there are practical steps that you can take to give yourself some relief in the circumstances. And so looking at those resources, looking at what you can do for yourself, even when you can't affect the larger system, I think is really key. And just remembering that when you're taking those steps, it's not your fault, it's not because you're doing something wrong, you're just trying to make sure that you are empowering yourself for success. And I think all of that looks different for everybody. So then you really have to think about what works for you and what will give you the best ability to kind of find that balance and that, whether it is finding that community at work. And I think for me, that is a big piece. Like I love having a community at work and people to kind of talk to and bounce ideas off of and things like that. So that can be a big piece for me. It can provide a lot of fulfillment at work. Another, sorry, CJ. Oh no, I was just gonna say real quick, kind of that community piece. So at least she's actually part of our wellness committee. One of the things that I realized very quickly in doing this faculty wellness was that we have a lot of people and the reason that I was fulfilling this role was that it was just too much for one person. And I really had some difficulty. I took on this role during the pandemic and there were just a lot of challenges. I was brand new as an attending as well, just figuring it out. And so it's funny, we're talking about community. We do a weekly meeting. I mean, excuse me, a monthly meeting as a wellness committee, but we kind of strategize and plan around faculty wellness in the department. But honestly, one of the benefits that I have seen without even realizing this was gonna happen is we've actually formed a bit of our own little community. So we spend some time just talking about life and what's happening in each other's lives and how we can support each other. And so that's been something that I've really enjoyed as a thing that we've done as well. Yeah. So Matthew asking anecdotally or otherwise, is there a thought that particular compensation models tend to be more conducive to a burnout-free career and why is it locums? I mean, I would say for me, it's having some degree of control and choice. So knowing that I have a choice is really key to me not starting to feel too burned out because I know that if I'm in a situation that I don't like, I have options and I can change that situation. And so I wonder if part of what you're suggesting there is in locums, you have a lot of control about what you're doing and where you're going. There's also other situations like for those maybe that really enjoy academics and doing things that aren't just clinical care, it gives them options to teach or do research or do other things. It's, I think when it becomes more of an obligation where you're trying to run on that wheel and trying to keep up with it all, and it's no longer feeling like something that you want to do, that you have the choice and the control to do, that it becomes a bigger problem. And so for some people, maybe being in private practice and having control over who you see and how many you see is more important. I have a colleague in a different specialty who has an innovative model of care where he runs his own practice and it's entirely cash-based and no insurance. And that relieves a lot of the responsibilities that he didn't wanna deal with and gives him a lot of satisfaction in his career. So there's a lot of innovative models out there and I think it's becoming even more recognized now as we're seeing higher rates of burnout and people are trying alternative things. But while it's maybe not what we trained with and it's a little bit harder to figure out, knowing that you have those options and you have the tools to try these things, I think is important. And again, trying to empower yourself to recognize your options, to not feel like you're stuck and can't get out. Yeah, I mean, there's a lot of benefit too. I have several friends who are doing more of the locums approach and many love it. I think a lot of it just sort of depends on what you're looking for. For some, I think for me, that wasn't as much an option. I wanted to kind of keep my family where I was and just young kids and just, it'd be tough for me to be away based on different assignments. But another thing that I've seen is also where, it seems like, and I won't speak for all academic centers, but I know one thing our department has done is it's kind of moved more towards a sort of, their sort of base salary plus incentive sort of base bonuses, especially as you get out of, I don't even know if they're still doing it, the initial two-year contract stuff. But it seems like there's been a shift and a pivot there. So at least in a sense, you're getting some credit for the additional work you're getting, you're doing, taking on, I still think there needs to be a balance there, but like you're at least getting a little more credit as you're taking on patients and seeing more folks. If that, the compensation side is what's important to you, for sure. I mean, I think it has to be to some extent for everybody, but maybe a spectrum on that. So. It's hard, especially coming into your first job or just early career, I mean, to know what all those options are if you haven't had some experience with that. And sometimes you can feel kind of pressure to take certain things depending on, if you need to be in a certain location or something. So there are resources out there, or research out there on sort of different models, ask colleagues too for what their experiences have been as you're negotiating your contracts and such, because that can have a big impact on your eventual work-life satisfaction. And then, yeah, I think Dr. Martin has said this, and it's not quite on the compensation train, but yeah, like trying to, even if you're in a more academic setting or not as much of a private practice setting, you usually still can have some control over your schedule. I think it's just feeling empowered to ask for that. I know, so this is my, Vanderbilt's my second job, and I definitely can say like it gets easier over time to ask for these things, but it's still, at least for me, it's still very hard to do, but yeah, just kind of saying, no, this is what I want my appointment length, this is how long I want my appointments to be. This is how I wanna do my administrative time and trying to, that, outside of compensation, but kind of still in at least how you're structuring your day can make a pretty big difference. Do you have any specific supports that you can think of, or either of you can think of that are helpful to either look for as you're looking for a job or to ask for in your job that might help either address some of the system issues or help your own efficiency, just make things a little bit easier? I can weigh in on that. I think it's something that I'm still thinking through, honestly, like what I would have done differently in terms of asking those questions. I think one thing is I'm thinking about clinic is just getting a good understanding of breakdown of support, ancillary support in terms of, do you have enough nursing staffing to help manage in-basket messages, and triage some of those things? Do we have enough staff in-person, in-clinic to get folks moved in and out of rooms efficiently? I mean, it can be kind of tough to know how to ask those questions, but I mean, you can just keep it open-ended, like, what does that look like in your clinic, just so I have an understanding. I think that other things I would have, other things that I would suggest sort of inquiring about is, you know, if you're a nurse, what I'm thinking about is, you know, going to the inpatient side and what, you know, what are the coverage sort of dynamics? How many people are in the coverage pool if someone needs to be away or multiple attendees need to be away? You know, what are the expectations that have been established for case management? There are certainly some who do more than others. So really, you know, kind of, you know, if you're pursuing an inpatient job, sort of thinking through some of that. If you're at an academic center, getting an understanding what resident expectation is and, you know, fellow expectation is as well, just so you can have a clear picture on, you know, where you fit into that sort of scheme as well and how much support you may have. You know, obviously the priority for our learners is to learn, but just getting a sense of how much coverage is there, you know, can be helpful as well. Those are just a few things that come to mind initially. I think one of the things that frustrates me sometimes when I see these discussions are like employers, like rolling out things about burnout and trying to address burnout is there's such a focus on trying to make the individuals more efficient, which feels like kind of a personal judgment of, well, you're not efficient enough, that's the problem. And when really it's like, well, actually, no, it's the volumes are too high for, to be practical for what I'm doing, or, you know, you're not giving me the proper support to do what I'm doing. And so I think, well, yes, we wanna be efficient. We don't wanna be doing, you know, wasting our time and excess work that we don't need to be doing. Trying to recognize what can make a bigger difference in your practice and not just put it on you is important. So whether it's, you know, the scheduling system or your inbox support, like you mentioned, or your case management and social work support for inpatient or outpatient, I mean, those are all things that can really offload a lot of time and stress. And again, we're supposed to be working as a team in PM&R. So we really wanna have all those team members that we need. Anyone else wanna ask a question or, again, this is very informal. So if you wanna speak up, share an experience, please do. Is it okay if I just speak up since I'm a slow typer? Go for it. Thank you all for those amazing answers to all my questions. I, this is Matthew Omedeo again. I'm really curious how to be a good attending in the sense of like, how do you be a good, I don't wanna say like boss, but colleague, you know, like thinking about bringing in breakfast and all that stuff is great, but how do you really feel about, like, or think about connecting with your staff, making sure that they can trust you, that they can come to you with any concerns they have. And, you know, aside from just being a wonderful human being like, how do you think about that? Well, you'd be surprised at how far being a wonderful human being will get you with that group. I mean, I think that sometimes that's underrated in terms of just being someone who's like, underrated in terms of just being someone who's approachable and tries to be nice and tries to be someone who's hearing out concerns or issues as they present with your team. So I would say that's a big one. But then, yeah, I mean, it's being intentional. Certainly some of the things like bringing in breakfast, you know, I sometimes, I do this thing with the brain injury team where I try to, you know, get them like a Starbucks gift card on their birthday. And I used to actually send something out to the whole department for our faculty and residents if they sent in their birthdays and wanted me to. So, I mean, those types of things can kind of can foster some community and people just feel good being highlighted. But I think trust is built with time. And I'm thinking of some of the inpatient, like the inpatient team, for example. You know, certainly where I am currently with them is very different from where I started when I, you know, when they didn't know me, I didn't know them. And we were just trying to make it through the days taking care of patients. But I think, you know, at least what I tried to do, you'd have to ask them, but I try to, you know, foster an environment that really supports all members of the team and, you know, that people can feel comfortable presenting ideas on patients or concerns on patients. Like if someone's not looking good, you know, and in trying to work together to think through ways to systematize the more common things we just are dealing with all the time every day. That's kind of, I feel like that's taken me pretty far. I mean, obviously I'll welcome any thoughts from our other experts here, but those are just some things that helped me. It's actually, I don't think it's as complicated as sometimes we make it. Like, I think it's just really, really, you know, fostering that environment where people can approach you about things. And I agree. Yeah, like when I was, when my last job where I was on inpatient, just with our team rounds, just always kind of asking like, hey, what is, you know, what is your, what did you think about like asking PT? What did you think about their like, their lower extremity tone? Like, this is what I saw. What did you think? You know, and they're, people are usually excited to have their opinion, you know, asked for. And then once they realize you'll listen to it and take into account, then that starts to really build up that trust. And then there's just that little bit too of if there's that extra minute where, you know, they have a picture of their dog on their phone, you can be like, oh my gosh, so cute. What's your dog's name? You know, like the personal connection. But I think just showing that you're interested in their ideas. I've noticed that was, you know, that really made a huge difference. And it was, and again, like CJ said, you'd be surprised how far being a good human will go when you've been around people who have never really had someone say, ask them, what did you think about this? Then, you know, that's like mind blowing to them. And if you have that moment to like, like you were saying, being really intentional of a time to listen and let them know that they're being heard. I remember when I started, I was so wrapped up in just everything that I was trying to get done and so busy and like, you know, trying to be a new attending and whatnot. And one of the nurses was like, you know, it would be great if we could have a time where we could all sit down and just like go through and run through everything. And that was one of the best suggestions because now where we have a chance to all, just everybody on the team, it doesn't really matter what their level is, has a chance to like talk through concerns, talk through issues, you know, figure out what they want to bring up in a supportive environment. I think it's brought the team together really, really nicely. And the same kind of goes in some of our multidisciplinary clinics and things too, where making sure it's not just the physician's voices that matter, you know, it's everybody's voice and making sure everybody understands the value that they're bringing really just makes a really lovely work environment, so. Other questions or things we can help with or hot topics. This is the time. I put a couple links in there that I had. If others have links or things resources they want to share for everyone, please feel free. And there's a lot of good stuff out there and sometimes it's just kind of waiting through it trying to find it. Yeah, there's a wealth of resources. So it's definitely just figuring out which works for you and kind of which one seems like it offers something new and novel. I had a question I couldn't, I was trying to decide between typing versus coming off mute with my kids in the background. But could you comment on, like, as an early career attending with residents, like how to be honest with the residents without biasing them against like administration or sort of, you know, like, I don't want to necessarily, like, poison is not the right word but you know like, again bias them against administration and foster more of like administration versus physicians type of aspects. Like how do you find that line of being honest about the challenges you might face as a new attending and trying to find that balance of like ensuring your work life balance versus versus not, you know, facilitating a poor relationship with the residents with their current administration. That's a good question. And I think a tough one because I definitely definitely been in that situation before where it's, it's a resident or any trainee who's with you maybe like on a bad day or something you know even where you're trying to be like okay, I need to stay professional in this scenario and not just express my frustration. trying to be objective and not. It's hard to say but like not pointing fingers as you're describing a system issue and maybe it is just that maybe it's just saying okay this is a bigger system issue, and this is a frustrating scenario. This is how we need to deal with it because in all practicality, you need to know how to deal with it in your future career you need to learn how to do this. But also recognizing that we know like it's not this one person that's the problem or this you know, we really need to look at it as objectively as possible. Yeah, I was trying to keep it general in that way I think similar to what you're saying keep it general or it's not like, oh man, you know, Mr. Smith always says no to what this but just you know, you know, a lot of times different places will say no to this and this is why but yeah it's, I think the hardest part is if when they're, because you know PM and our training they're with you one on one, so much more than like other specialties where they're in their little team and you're off separately like the resident that I have with me, he's with me the whole day. So like if it's much easier for him, or for them to catch you in that moment where you're like frustrated and you kind of say something that you didn't you know necessarily want them to hear so just being mindful of that too. Yeah, yeah, I completely agree that agree with everything that's been said, it is a balance because, you know, in one sense, excuse me, in one sense you don't want to over shelter. You don't want to reveal too much too soon and you have to be careful about how you're doing that but then you also don't want to over shelter. I have had pretty frank conversations with our residents just about, and I try to again as, as the panel has mentioned I try to stay objective and not, you know, not do personal attacks on individuals or anything like that. But I do, I do think that it's important for them to understand some of the system things they're going to be faced with as a transition out and I think that that can help. And I don't want this to come out the wrong way, but I think that can sometimes help move them further along in terms of professional maturation, because sometimes you can kind of get into a mode where you're thinking your, your life outside of residency is going to look like your life in residency and that's really just not the case so they need they need somewhat of a little bit of a reality check, but I try to not have it be totally disparaging and you know just there's no hope at all, you know, I still try to have an optimistic sort of spin on things as I'm talking to them. And, you know, we were advocating we're fighting for what we think we need. And sometimes these things take time. I mean there's more discussion around wellness now than there, you know, at least than I remember there being when I was coming through medical school and, you know, so just, you know, there's been some progress at least in terms of broaching the topic. I try not to gripe and complain and get too mad about insurance companies and peer to peers, but at the same time we all have to learn how to deal with them so trying to trying to be professional about it. But I do think I agree it's good to expose them to it because if you didn't get exposed to it in training than the first time that you have to deal with it as an attending you're like looking for somebody to be like, um, well, I have to peer to peer what do I, what do I say what do I do so you know for at least to kind of at least talk with them about it. And kind of demystify it a little bit as much without being overly negative. And know and know that they can say you know like you might deal with some person who does not know what they're talking about and you don't just have to take it as it is you can fight back and you can bring your evidence and you can argue for your patient. Try to empower yourself a bit. Yeah. Absolutely, absolutely. Just, you know, it is a, that's the one where I sometimes it'll slip out, I'm not going to lie to you all I'm not even going to pretend on this call it when I'm dealing with some of these insurance companies, you know, it does slip out a little bit occasionally but, you know, but again it's all advocacy and honestly there isn't an industry where you're not going to be dealing with something, you know that you would prefer not to so I don't think, of course, in an ideal world we'd have to deal with it. We've got the perfect job with no stressors and no things that are going to make us, you know, you know, angry or disappointed with the system but we want to, I mean, when we can minimize that as best we can and that's, I think a more attainable goal. This personally. Well hopefully this has been helpful for everyone. So again, this is a, it's a difficult topic it's a very active topic, and I think something that we all need to continue advocating for is we're trying to make the situation better. Because clearly we've got physician shortages we have expanding volumes that we need to help with PM&R as a field we need to keep growing to meet the needs. people to be able to find the satisfaction in their job because we've got pretty incredible jobs we're pretty lucky to do what we do. So, I hope this has been helpful. And I think finding those people that you feel comfortable talking about this stuff with again because like Dr. Martin said from the AFP you're not alone. It can feel like it sometimes if you don't necessarily have somebody you can talk to and in the talking about burnout can feel like a very vulnerable space because you know as much as as much progress as we're making in terms of seeing it not as weakness, you know, I think people still have a hard time talking about it, too. Yeah, absolutely. Fantastic questions and I've just, you know, and I've learned a lot even as I feel that as we feel that some of you all's questions and gotten some of your thoughts as well so we really appreciate everyone's engagement. I think we all learned something with CFTR today to at least the panel. Thank you. And I'll blast that out to the, to the department. Thank you Dr. McLennan, thank you Dr. Plummer, thank you for organizing all this. And maybe we'll end it there so everyone can go enjoy their evening. Yeah, thank you all so much for attending and for your participation. Thank you so much. It was wonderful.

burnout

early career physiatrists

challenges

strategies

medicine

PM&R field

open communication

supportive community

self-care

well-being