All right, if everyone can start getting seated. All right, good afternoon, everyone. Welcome to our session on it's okay to not be okay. We did make this presentation back in January, so this does not have any politics within it, but it does seem to be for, it's not politically related, I'll just say that. I'm Jeremy Roberts. I'm a sports fellow at Atlantic Sports Health at Morristown Medical Center. I did my PEDS Rehab Fellowship at University of Colorado. I'm here with Megan Machak. She's a University of Colorado PGY-4 resident, and she'll be doing Sports and Spine Fellowship at Vanderbilt next year. And then I'm with my former co-fellow, Dinesh Ratnasingham. He's a Clinical Assistant Professor of Pediatrics and Pediatric Rehabilitation Medicine at Kansas City Children's Mercy through the University of Missouri, Kansas City Medical School. In terms of disclosures, we have no relevant financial disclosures. We will be discussing physical health, mental health, and family health, which can be a traumatic conversation for some. So at the end, we'll have time, and we want this to be an open space for people to either talk about or express any emotions or feelings or thoughts that they may have. We will not be discussing parental leave as part of this talk, but we do understand that it is an important component of all this. And the last thing is, we don't really get too much into the concept of resilience, but resilience is still very important to consider. All right. So as a prompt, many of us here have either issues at home, issues with a pet, family health issues, personal health issues, financial stressors, high work burden. We're all dealing with something, and no matter how well you think your colleagues are doing, something is going on. During this talk, we want to compare and contrast different real-life personal challenges that really anyone, including trainees, may face. We want to obtain strategies to face personal challenges and pursue goals. We want to create a list of resources and people that one can reach out to in order to get assistance that they may need. We want to obtain strategies to manage your time during training or during practice while facing your personal challenges. And we want to have, again, an open space to talk with your colleagues about any struggles that we may be facing and to have empathy for each other. So overall, we want you to look to your left and look to your right. All around us, it seems like everyone has everything under control. Everyone is very successful. Many of us may feel like that we're not doing enough. You look to your left and right, you're like, how is that person doing those things? And that person is looking behind them and saying, how is that person doing those things? And they're looking across the room and saying, wow, that's my mentor as well. How is this all happening? But the reality is that we're all facing something. And for some of us, it is OK to not be OK, even if we are struggling. Each of us is going to present a different aspect of a personal challenge, whether it's mental health, physical health, or family health that we've all encountered during our training. And then we'll each discuss how we have continued to achieve success and pursue our dreams of becoming compassionate rehab physicians. And the hope is that any medical students, residents, fellows, and attendings can take away from this that it truly is OK to not be OK, and you can still thrive. So my personal story, again, this was made before Dr. Flannery spoke, but I was diagnosed with testicular cancer during my pediatric rehab fellowship. During this time, I was living in Colorado. My wife was living in New York City. And from the beginning of Pete's fellowship, I was also planning on doing a sports fellowship as well. So I was on a very specific personal timeline. So once I was diagnosed and had an oncology plan, my first priorities were, oh my god, how am I going to graduate on time? Or how can I stay on track to finish on time and then be able to apply to fellowship and start fellowship in sports on time, while literally everyone else, they just wanted me to be OK. And this included my family, and my program, and my friends and colleagues. They were just looking after my health. I was focusing on different things. So I worked with my program director immediately to relay the oncology plan. And I do want to emphasize that she wanted me to take time off and wanted me to focus on my personal health. When I rebutted and I said, no, I have a fellowship that I want to do, she was very helpful, and we troubleshooted to come up with a plan where I could still work, still graduate on time. Work pretty much non-clinically and do a bit of a research block. But we spoke multiple times a week, and we spoke on the phone weekly, and she offered me to take the time off that I needed every single time and said, are you sure you don't want to take time off so you can focus on your own health, to which I replied, I appreciate it. I want to be doing these things. That helps me stay motivated during my treatment course. And while I was at home. So during this summer of personal health chaos, I was still doing some lectures, presentations, my own, some research, some publications. So I was able to be productive, and that felt very good, and I think that helped me along during my own personal treatment. And then ultimately, I was able to complete my year in time, and I was very lucky and blessed, and I got to match into a sports medicine fellowship and graduated in June and now doing a fellowship. So of note, during this time and during my interview process, I opted to only mention my diagnosis and treatment very briefly. I want to just focus on the work that I had done. I only used it in a context similar to what Dr. Finery was talking about, where it gave me a different perspective on empathy that I had for my patients, especially going into sports medicine, where we tell people now, you're not allowed to do your sport or your activity or the thing you love for X period of time. And after my chemo and surgery, I was told, hey, you can't do this for X period of time. So that helped me attain some empathy, but that's pretty much the only way that I brought it up. So the overall lessons that I learned is that health really is the number one priority in spite of all the things that we're doing. When you're looking to your left, looking to your right, going like, how are they doing all these things? Health should be our number one priority. My PD, coordinator, colleagues, attendings, program, they were all incredibly supportive of all my needs. We spoke multiple times a week. You really never know what someone else is going through, if they're having a rough week or if they're taking a little more time off than expected, especially this is more for trainees. But when you have to cover for others, don't assume that you're being taken advantage of. Those who are working hard, well, that'll be seen as working hard. If someone's gaming the system, that'll become evident. But the first assumption shouldn't be that they're gaming you. It should be that you never know what someone else might be going through. And a big thing that I learned, and Dr. Flannery also mentioned it as well, is you want to make sure that you attend all your appointments as needed. You do have more time to do this than you think in spite of all the hard work we're doing. You've got to be a little flexible and make sure you go to any follow-up appointments, labs, imaging, dentists, whatever you need. And the other lesson was in terms of work burden, everyone does have different capacities and you have to find your happy spot and feel like that you're being challenged without feeling overwhelmed. So these were my own personal lessons. And then in terms of practical applications, so what can we do as a field in physiatry and pediatric rehab or when thinking about our academic educational training process? ABPM&R, I learned they have a policy granting four weeks of additional consecutive leave time that can occur as a single event. So that was nice to have on hand in case I wasn't doing well enough that I would still be able to be productive with non-clinical things and I just needed to take more time off. Another thing to consider, and I didn't know this existed, was intermittent FMLA. So instead of taking a chunk of time off, it's intermittent. So if you have to leave work to do a couple therapies, get labs, get imaging, go to some appointments, but you could still be full time at work. This was very important for me to have and it gave me a ton of flexibility as I was finishing up my Peds Rehab Fellowship. Another thing is that it is up to you how much you disclose about your physical health. I'm an oversharer, so everyone knew everything about me, but it would have been totally okay if I just said, hey, I have a personal health thing going on. I'll talk more about it later, but for now, I'll need to take some personal leave and go back home to New York to take care of myself. And then another thing that came up, and this became very real for me, was really thinking about your benefits package. We think about so many other things, and I know it's another thing to lump on, but thinking about your disability insurance, their disability benefits, your health insurance. I'm not going to say I'm lucky that I had to go through everything, but the fact that I was able to go through everything while training meant that I was getting a set salary and I didn't have any specific RVU productivity. But if I had gotten sick and I wasn't in a fellowship, now if I wasn't able to see patients, I wouldn't be able to generate revenue and I might need to use disability insurance, even if it was like one year later with same treatment plan, same illness. So it is something to consider when looking at either fellowships or your packages when you're looking for jobs. And then thinking about our patients and practical applications for them. So a lot of this will be a bit of preaching to the choir, but we want to be working with Child Life and the Neuro or Rehab Psychology team. We want to be able to help model phrases and help script for them that will help them explain their physical health to their peers and for parents to their families. We also want to be working with school teams to make sure that our patients have the appropriate accommodations as they get back into school, whether it's as simple as no gym class or as complicated as they'll need one-to-one or anything in between. Working with the school teams so that their teachers and staff have understanding as well. Emphasizing anticipatory guidance for them so that our patients and families know what to expect, know how many follow-up appointments that they're actually going to be need, that if you had your brain injury, we've got a long road ahead of us, or every six months you're at an interdisciplinary clinic, call us if you need anything along the way, or every week you're going to need to be going to multiple therapy sessions, and again, everything in between, just so those expectations are set up for them. And then what was huge for me was making sure follow-up appointments are made. Where I was getting treatment, they were very on top of things. By the time I had left treatment, they already had five more appointments made for me, but it was just easy to already have it on the schedule. And there were some patients while training where it was either complicated to make an appointment or whatever subspecialty, they said, no, we'll call them afterwards. And I can understand that can be very challenging for our families to not know when subspecialty X, Y, or Z is not going to call back, or they don't have all their appointments lined up, and that adds to an already stressful situation. So those were some of the things from a physical health standpoint, and now I'm going to hand it off to Megan to talk about mental health. All right, so hi, I'm Megan Maychek, I'm PGY4 at University of Colorado, like Jeremy said earlier. I'll be talking about mental health and training. My story, to start, medical training is hard on everyone. No matter what happens while you're in training, this is not easy to go through. Pretty much everyone gets taken out of their home, is away from their normal support system, is experiencing life in a new place, in a new culture, and probably away from the people they usually get to lean on in those situations. So where I did medical school, I had it split. I did two years in one place, then moved to do my clinical training elsewhere. About two weeks after I moved, which was right after we took step one, when we still had step one scores, which made that more fun too, I ended up being in a double homicide. I was hiding in my bathtub for what felt like hours, I have no idea how long it was. About 200 rounds went off by the time the SWAT team came and was able to get me out of the situation into safety, which resulted in me having some pretty big PTSD symptoms. Anytime there was a loud sound, a loud bang, I'd find myself, if I was in my apartment, ending up back in my bathtub, or if I was in my apartment, I'd get really shaky, I'd notice I'd have pretty quick breaths and have to step away from the situation to calm down. It took a while for me to realize how much this was affecting me, whether I was back in my place or whether I was at work or with my friends, with my family. And on top of this, it was the very beginning of my third year, so it was the first time I actually had my own patients and seeing their traumas and trying to walk through their life traumas with them while figuring out what was going on with me. My immediate concerns, pretty similar to Jeremy's, were I'm not sleeping already, how am I supposed to be learning, how am I supposed to be getting to work at four o'clock in the morning for my surgery rotation, how am I going to do 28 hours straight of working when I haven't slept for the last month more than two hours a night? What happens if something drops in the OR? If someone drops a big metal object on the ground, that's a very triggering sound for me at this time. And what happens if I react to that without being cognizant of it? And it affects patient care or whatever, the sterile field, all the fun things. How am I going to get through my exams? Not only study for them, but for some reason, of course, at that time, there was a lot of construction going on where we did our exams. And any loud noises were big for me. And so it was just hard for me to stay focused at any time. I need a residency. I knew I wanted to do PM&R. I knew I wanted to go to a program that my test scores might not have been good enough to get into. So I need to do a million things and get all the best grades to get into this residency. And none of this is very easy to do in general, much less when I'm figuring out my own mental health at this time. So what I did, like I said, it took a long time for me to realize what was really going on and how much I was affected by this event. It took me failing and messing up a few times to realize I needed help. By the time I actually admitted that to myself, I was able to go to our assistant dean of student affairs. And I was able to tell them what was going on. They were really helpful at the time. And I actually asked for time off because I was so scared of being in some of the situations I mentioned earlier. And sadly, and what's really the reality in medicine still, which it shouldn't be in my opinion, is I was told not to take time off, like an extended period of time off for mental health reasons. Because if I was to apply to residency and people found out, I probably wouldn't be able to get a residency. And they said that lovingly, like, we'll let you take time off, but be aware that that's the stigma out there. So I did not take time off. And instead, I was encouraged to talk one-on-one with the attendings I was working with. And the clerkship director, be vulnerable with those people so that they could help work with me. I could get the help I needed and be as present as I could on my rotations and do the best I could that way, which is what I ended up doing. And I had a lot more support than I originally would have expected to by doing that. They did let me leave in between procedures or in between clinics to go to therapy. They worked with me on scheduling me on certain people's services on certain days. If I didn't sleep a lot and I had a 28-hour call, they'd make sure to kind of like shuttle me out and help me get naps when I could, which was really nice. I was able to use medical school resources to get further help. So a lot of medical schools offer therapy and things like that. And it's usually based on, like, school is stressful. A lot of people get depressed. A lot of people get anxious just while in school. And even though a lot of what I was going through wasn't necessarily school-related, they did help me find ways to use all of those resources. So once again, the Assistant Dean of Student Affairs and those attendings really did work with me and work within the system we're in. I also had to learn how to prioritize my mental health and my physical health and put that before school at times, which I think we're all pretty much trained not to do. But being able to reflect on, this is what I need to do to get through this short period of time and make it so, in the end, I'm better for my patients and I can do more in my career, was really important for me. Like I said, medical training in general is hard. And it's OK to admit that. It doesn't take a traumatic event for this to be stressful on all of us. And it shouldn't take that for us to realize our mental health can affect us on our day-to-day. It's important to continuously reflect on how we're feeling, not only outside of work, but while at work and what is affecting us minute-to-minute, really. It's important to also remember to get help before this turns into a crisis. I probably had a lot of anxiety and things going on with step one and everything else before this event happened, which probably exacerbated everything. So it's important to realize when you're starting to struggle and start looking for resources at that time instead of waiting for it to turn into a crisis and it to become too late. Additionally, we're all in rehab. We see some of the most traumatic patient interactions every single day. It affects us. I think a lot of us like to pretend it doesn't. And I know I personally like to see my patient and be that superhero for them and cheer them on. But at the end of the day, I sit in my car and I reflect on that over and over. And it's hard to turn off. And I think it is for a lot of us. It's important to realize the emotional toll it takes on all of us to see these traumatic situations and how not only it affects our patients, but also their families. And we also need to help our trainees, whether it's residents who are going into this field or medical students who are experiencing some of these traumas for the very first time, realize that it's OK to be affected by our patients and by hearing what they're going through and by what their futures might look like, and teach them how to best deal with these situations. So things I learned that it's OK to ask for. Mental health resources. I know that there is so many thoughts on what a physician should and shouldn't be and what we're supposed to be able to do completely on our own. But it's OK to ask for resources from your people, whether you're in med school and you're going to your dean of student affairs, or whether you're in residency and going to your program director. It is OK to tell them that you're struggling and you need things like therapy. It's also OK if you end up needing medications to help with some of your mental health things. I think for a lot of us who practice medicine, that's a whole different thing than therapy for some reason for all of us. And a lot of people are very scared to be on medications because of things like licensing boards and all of that. I know when I was in medical school, I had friends who would go to private practitioners paying cash for their appointments and paying cash for all meds so that even insurance wouldn't have documentation of what they were taking, which is absurd and just absolutely not where our field should be headed because we need people to be mentally well to best care for our patients. It's OK to build time into your day to decompress. Something I learned is if I could walk away for just five minutes, do some breathing, take myself out of the situation and calm down, I was so much more mentally present the rest of the day. And I could be a better doctor for my patients and a better team member for my team. So build that time in in those times when you really need it. It's also OK to ask for time off. I was discouraged at the time, and it ended up working out for me. But had it not, it's very important to take time off when you need it. And a mental health day is a sick day. If you are going to work and you are not doing well because of your own mental health, you are not present for your patients. You're not going to give them the right care they need. It is so much better for you to take time off, focus on yourself, get yourself right, so when you are at work, you're actually there in the best you can be. And give yourself that grace, too. So things to consider and things I hope that we're all moving towards. In your programs, in your work environments, is there really a safe space for people to not be OK? We get so many lectures about wellness or sleep hygiene or mental health, but that doesn't necessarily make it so that we, as trainees at least, feel that it's OK to not be OK and OK to have mental health problems. So how can we make it so that people actually are feeling safe to come to us as leaders, whether you're a senior resident, whether you're a chief, whether you're the chair of the department or a program director? How can we create that so that people can come to us when they're struggling before it's too late? As I talk to a lot of trainees around the country, I think a big thing is vulnerable leadership. Whether that is leadership that says out loud, hey, here's something I struggled with when I was in training. Here's how I dealt with it. If you're having trouble, come to me. Or whether that's just saying over and over here are the resources and making it really clear where people can go and that they can come to them at any time for struggles. It's really important to let people know they can be vulnerable with you. Also, discussions on rotations. Like I talked about earlier, we work in a rough field for mental health. And it's really important that while we are seeing these traumatic cases, we're realizing it. I think a lot of times we'll see something so terrible and then someone will crack a joke so we can walk away and go to the next patient and deal with the next trauma, which works from time to time. But a lot of trainees across the country are not being taught how to actually process some of the things we see, correctly reflect on them, and then from there move on to the next one. And I think it's really important as we want to bring more and more med students into our field, but also as we are coming up through the ranks as trainees and as attendings, we're going to keep seeing these things. So how can we deal with them the best so that we're not getting burnt out by these situations? When you're looking back on your programs, how often are our residents, our med students, really being checked in on? Once again, not necessarily everyone sitting in a group and being like, hey, everyone doing well today? Great. But actually spending one-on-one time with someone, letting them be vulnerable with you and open up to you with what's going on. Once again, this could be like resident, anyone from a resident reaching out to a med student, to your program director, to your student or your program director, to that attending when you see that really rough patient and you can see a resident's face kind of drop when they're having to present the case, catching up with them afterwards. A lot of things I've heard from friends across the country that have been great are, there's a few people I've talked to where their attendings every Friday kind of schedules like half an hour with the residents on their service and they'll go do a coffee walk. So it's like, you know, like Megan at 2.30, it's mine and your time. We're gonna get a coffee and walk around the block. And you know that's your one-on-one time with attending to air any grievances, to talk about what you're struggling with. Not necessarily talk about medicine, but to talk about life around medicine and how you're being affected by it. Further, how easily are mental health resources available where you work? And what does that really look like? As much as I personally disagree with this still being a big faux pas that people have mental health issues in medicine, there are a lot of places it is. So can you get these resources anonymously and how do you even find them? In my experience, I was really lucky. My medical school had therapy available for all students. All we had to do was call, we had the number of the therapist, call the therapist, we'd get appointments. And the school would just pay for it anonymously. So they'd be told at the end of the month, like, hey, we had 200 appointments from your students. And then they would pay for those 200 appointments. I've heard that this is also happening in different programs across the country with like Talkspace. They just get like a generalized bill from Talkspace at the end of the month. And it's not told like who's going and how many time each person's going. So is this available at your institutions or is this something we can work towards? Also letting people know, again, when you're in leadership, like making it really clear, it's okay to take sick days for mental health. If it's really between you showing up to work and maybe not doing a great job, not doing patient care, getting more and more burnt out versus taking a few days off, getting yourself right and being able to be really present in the best you can be. So yeah, thank you. Dinesh will take the rest. Hey everyone, I'm Dinesh. I just have a great reverence to be on this platform with Megan and with Jeremy. And just want to thank you all for kind of sharing this space with a vulnerable audience and allowing us to share some of our personal experiences. I'd like to add to that as I kind of go into this section that I had the opportunity to contribute to. I'm the child of two incredibly wonderful people and they sacrifice and give so many things up so that I could have any opportunity that I wanted and needed in my life. And one of the proudest moments I remember on their faces was because as long as I can remember, I wanted to be a physician. And so getting into medical school was a huge celebration. And once I got to medical school, I wanted to do anything and everything I could to be the best physician I could be. And I was nominated by my peers to kind of be a leader for our class. And I tried to do everything that I could, not just for myself, but for them. And it felt good and it felt great. And I took every opportunity academically and extracurricular and try to just do as much as I can to be the best medical student I could be. During my medical school journey, my mother was diagnosed with ovarian cancer. And I think that was the first time in my life that you learn about that physician patient relationship, but I was truly on that patient side of things. I had to interpret things for my mother and father. I had to sit down after appointments to be like, actually, what does this mean? Or like, how does this break up our participation if we're using ICF models? You know, like, what does this mean now? Like, how do we readjust? There's never a such thing as normal, but now what does our normal look like? And going back to medical school and trying to also be a son was really, really hard. Trying to be a leader, trying to do all the things that I thought I wanted to be as a physician became a bit of a challenge. And so I had really, really close friends and I had amazing mentors. And they told me to be a son and to take that time. And so I took time away from medical school and I was there for my mother. And it was the best time that I could have ever had. I was able to be there for her during surgery, during chemo, during radiation, during palliation, and during hospice. And I was able to be there for my father too as he was processing all of it. After her passing, I moved my father up to stay with me and there was a role shift of like, oh, I'm the sole breadwinner now. And oh, I am a son that's taking care of an adult parent and we are both grieving. My father has mental health challenges and needs assistance with his activities of daily living. And so those were things that I didn't think about in my early days of medical school. I was just focused on me. And now it was, how do I balance all of this and how do I reframe who I wanna be and what I wanna do with my life? And that really shaped a lot. And I think all of us in the audience and all of us today have just kind of sat with the plenary talk in terms of like, what does this mean for us? One thing that he mentioned today that really resonated with me, he said, don't forget about the co-survivors. And it brought me back to this proverb that I learned when I was really young, Turkish proverb that says that fire burns where it falls. And so it's not just about the fire impacting the individual or the trauma impacting the individual, but wherever it touches, family members, coworkers, team members, we all have an impact based on it. And so how do we care for each other? And so going from medical school and graduating and becoming a preliminary internal medicine, I started to run codes, but I took the extra time after the code to check in with the team members, to check in with the patients, family, to make sure everybody had an opportunity one-on-one privately to just have a moment to reflect and debrief. I had the opportunity during my residency at Rehab Institute of Michigan to become a chief resident, and it was during the pandemic. And it was an intention that I made to check in with the other residents, whether it was them staying late, whether it was a phone call or a text or us just going to get coffee before didactics, even though we ended up late to didactics. It was me being intentional to say like, how are we doing and taking that one-on-one time. With fellowship and being with this amazing co-fellow right here, it was a lot of this team network, not just within our fellowship and our combined residents, but also the inter and intradisciplinary team and caring for each other as we navigated challenges that we continue to face clinically and personally in our lives. And now as an attending, I have an amazing support system at Children's Mercy, and I'm continuing to grow in that transition from being a learner through this medical journey to now being an attending and how do I practice as an attending and continue to be there for the learners that I get the opportunity to teach. So that kind of goes into this next phase, which is how do we respond to others? And the roadmap that we're gonna kind of focus on is how do we respond at a national level? How do we respond within our systems? How do we respond individually? And then for our specific patient populations? And then how do we take care of ourselves if we're providing this much support and if we're being there? How can we make sure that we are taking care of ourselves by providing that support? I wanna acknowledge that everything I'm about to present is from the collaboration that I've learned throughout my medical journey, throughout the residency, throughout fellowship, through programs like Captains of Inclusion and Better Together. And as an attending, working with the Children's Mercy trauma-informed care team for some of the slides that I'll be presenting today. So nationally, I'm pretty sure a lot of people in the audience have heard of this, but for those who haven't, in 2022, the Dr. Lorna Breen Health Care Provider Protection Act was passed and it supports healthcare workers' mental health and wellbeing with $103 million across 45 organizations. The goal was to implement evidence-informed strategies to reduce and prevent suicide, burnout, mental health conditions, and substance use disorders. And from this, they created the Impact Wellbeing National Campaign to really help healthcare workers kind of strive. And this was kind of created through the heart of the pandemic and coming out of that in terms of how can we truly impact all healthcare workers, not just physicians. The unfortunate part of this is that of all of that money, less than 1% of the 6,120 hospitals in the country received any funding from it. And so that left over 200,000 plus healthcare settings without access to these funds or these resources directly to improve our wellness that we can have individually. And so luckily, this is actually up right now in 2024 for renewed funding and with a renewed goal, specifically to widen the reach to more hospital systems and to focus on reducing administrative burden for healthcare workers. And it's been introduced and placed in both the House and the Senate. So if you are called and you have a drive, call your legislators, let them know that this needs to be passed, this needs to be broadened so that we can continue to receive funds. This wasn't just something that we all were facing during the pandemic. This is something that we all need, period. I think other things nationally to think about is something that Megan touched on, which is the concern of wanting to disclose something. And so we are starting to move away from asking about mental health in terms of documentation, whether it's for a job or for a licensure. And I think that opens the door for us as providers, whether we're a learner, whether we're becoming an attending, to have that open discussion and to feel vulnerable and willing to ask for help rather than feeling potentially stigmatized by having to document it and not ask for help. So within the healthcare system, we all work across multiple different settings, academic, private, a mix, a hybrid. And so the most important thing, it's not just about knowing this information for yourself, it's about knowing it so you can be informed and educated when someone comes to you and asks for help. What does your center of wellbeing look like? What are the confidential support resources, whether it's local, whether it's in the university affiliation, whether it's within the hospital system? Get to know that and get to know a little bit of the detail. You don't need to be an expert and this doesn't all need to be on you. The whole point of this, we've all learned throughout our journey is how do you delegate and how do you take a little bit of a path to empathize, to be there with the person and then guide them to something that they know is gonna help them in the long run. And it's on them to make a choice, but at least you have the information to provide it to them. So individually, this article that I'm gonna kind of reach out to you, the first time I read it was like, yeah, duh, the do's and the don'ts. Of course, I know how to do this, but it's so much harder to put this into practice and I've really been intentional when I first read this article and even now to be like, am I doing this and am I doing this and could I do it better? And how can I continue to have this growth mindset to take the next step with the next encounter to be better at this for the next person I reach out to? So the do's, who are we doing this for? Who's it benefiting? Is it for us? Is it for both of us? Is it for the person alone? I think during the pandemic as a chief resident, it was for both of us. I was reaching out not just to check in with them, but I was also needing support. Like none of us were able to know what the next day or the next week would show. There were changes that were occurring all the time and it was important for us to come together and to just sit in a space where we could share. I really like Ted Lasso. So this next one is to be curious, not judgmental, and to approach things privately. You know, Brene Brown talks about being able to sit in the darkness with someone and when they're ready to crawl out of the darkness, you can be there with them. And so that's leading with empathy and leading with respect. It's not about kind of imposing your wishes on anything. It's really allowing them to drive the ship, engage the support in terms of what they want or what they need based on it. Actively listen, acknowledge their feelings, repeat back what you're noticing and affirm what you've heard. And then actively offer support. As Jeremy pointed out, be there for them in the ways that they need you to show up for them. And don't judge it, just be there. The don'ts. Don't assume the needs, don't offer condolences or bring up private conversations in a group setting and do not project your emotions onto others. Again, when I read this initially on the journal, I was just like, yeah, of course, but it's hard with each encounter to kind of really take a step back and reflect, did I do this right? Are there things I could do better? So I think the highlights to kind of think about in all of our fields in rehab is that we all wear multiple hats and we all work well in our interdisciplinary clinical team. So it's the same thing when it comes to our wellness and when we're providing support. Who do we reach out to to accommodate the needs and how can that be helping them and helping us to find balance? It shouldn't all be on one person in terms of providing support. So for our patients, I think it's unique, right? Some hospital systems have like a special care clinic that's a medical home, but I think for most of us, our patients, their families, their caregivers, their support system view rehab medicine as their medical home sometimes. And when some things change in our patients' lives, who's really asking about that? Do we really take the extra minute on a consult or on an inpatient or in an outpatient setting to say like, hey, what's going on? I'm noticing a change and can we chat about this? And so when it comes to helping pediatric patients to disclose something, it's realizing that some stuff is just not normal and there's an inability to cope with any emotional distress and they're probably just wanting something to be done about it. They're wanting access to just somebody they can trust. They have this expectation that please believe me, but I think beyond all of it, they're just wanting somebody to ask them. And I think when I first talked to our trauma-informed care team about this, I was like, ooh, is there a script? Because I would really like a script. And so yes, there's evidence-based scripts that you can use. And so I'm just gonna read these words out loud. I'm here to ensure that your body is healthy and safe. We are made up of our experiences, good and bad. Some affect our health today and in the future. The goal is to build up what needs to be enhanced and increase the resilience that we already have. Stressful events like difficulty getting food, violence, loss are common and affect the child's health and development. To provide the best care, I ask all families, caregivers, and support systems their experiences. Stressful events can affect the health of many pediatric patients. Answering these questions can help to better understand you. These questions are designed to be completed by you alone. Now, many people in the audience are like, hold on. My patients may not be able to verbally respond or may not be able to write something down. So how do I actually do this? And I'm gonna get to that as we talk through our specific patients and our unique patient populations. For patients who are a little bit younger, it's using terminology and using language that they may understand. So has anybody hurt or frightened you? Has anything bad, sad, or scary happened? And then as a provider, if you're recognizing or picking up on potential shame or embarrassment that's being displayed, acknowledge it. You don't need to worry about anything you say here. We want you to be healthy and safe, right? You're not the one that's gonna be like documenting and doing anything from a legislative or from a governmental level. You're not the one that's gonna be like, documenting and doing anything from a legislative or from a governmental level. You're their provider. You're there to build trust and then provide resources either to your social work team, to CPS if needed, whatever they may disclose. You are the person that they're trusting right now and that's your main responsibility. So after they disclose, I'm so sorry that this happened. I believe you and what you are sharing with me and I will get you connected with someone who can assist you further and what you can do next. What happened is not your fault. And acknowledge their feelings and tell the patients that they matter. So considerations for our population and this is where I had a lot of discussions with our trauma-informed care team around this. And so I think it's common, especially when we think about like our spinal cord injury patients, the term like safe touch, especially when a family member, a caregiver, maybe even a guardian is starting to do cathing or bowel programs or do things that are in the private areas of the child. And then you go to the other end of the spectrum, like our adolescent and young adult population. And so when we think about our neuromuscular populations that maybe the parents are getting older and they're getting somebody else to be their guardian, what does safe touch look like now? And how do we build that trust in this patient population? For those that potentially have a cognitive impairment, see how they communicate and reframe your questions for them. So if they're already using a communication device, like an augmentative and alternative communication or AAC device, look at their answer choices that they have available and reframe your question to them. So they still have the autonomy to answer in the way that they can. If there's challenges around that, use your interdisciplinary team confidentially, reach out to neuropsychology and rehab psychology, reach out to child life, reach out to speech therapy or OTs, find avenues for these patients to advocate and have that autonomy to disclose confidentially. So that's a lot that I kind of just covered, what to do nationally, what to do within your system. And then when you think about like the do's and don'ts with your coworkers, oh, I need to be always debriefing and seeing how I can have that growth mindset to be better. And oh, I can actually add this, it's gonna take me 30 seconds to each clinical encounter that I have just to check in. That's gonna take a lot on anybody. And so how does that impact us and how do we process that? I think one of the things that we had the opportunity to learn during our fellowship was to be a part of a program called Better Together. And there's this cognitive behavioral health tool called the CTFAR model. And I'm gonna walk through it and then I'm gonna walk through it with an example. So what it stands for is circumstance, thoughts, feelings, actions and results. So your circumstance, which is a neutral fact, it's 100% true that can be proven in a court of law, then triggers the thought in your head. That thought is a sentence about that circumstance and you get to choose whatever that thought is. That thought is then gonna cause a feeling and that's a one word emotion that is always caused by that thought. That thought is then gonna fuel an action or an inaction. It's whatever you choose to do or not do that's being fueled by that feeling. That action will then create a result that proves the thought that you initially had. So let's walk through an example in terms of you trying to provide support. And then I'm gonna walk through it in terms of the reframe using a cognitive behavioral therapy. So the circumstance, you just had a really challenging diagnosis education session. Emotions got really high. The parents started to argue with each other and your intention of going in there to provide diagnosis about their child was not fully well received. Fact, that triggers a thought. So I'm probably feeling pretty inadequate. I'm feeling pretty frustrated by that situation. Those are probably some feelings that are kind of going around there. But in terms of the thought, it's like, wow, that was very hard for me. That was really challenging. And I don't think I did the best job, the best I could possibly do there. So inadequate, frustrated, afraid to maybe go back and continue to partner with these parents. Scared about how the rest of the interdisciplinary team is gonna kind of want an update of how everything kind of went there. My action, I may not show up as much. I may be kind of frustrated with myself and just kind of only focus on the bread and butter things that the child has, but not really address the parents as much. And the result, I'm providing inequitable care. So let's reframe. Same circumstance, challenging diagnosis education session. There were heated arguments and you tried to provide support for the parents, but it just didn't go well and you weren't able to complete everything you wanted to do. What's your thought now? Okay, this was challenging and I'm gonna show up for them. I'm gonna meet them individually. I'm gonna see what I can do to make sure that their concerns are heard. Now what's my feeling? I'm feeling empowered. I'm feeling that I have an opportunity here to build a deeper relationship with each of these family members that's then going to translate to them participating in our rehab program more so that this patient is going to receive even more care, not just from our team, but from people that they trust within their family. Action, okay, yeah, I'm showing up for them. It's gonna take more time, but I'm spending what I feel is important. And the result, I'm providing equitable care and I'm meeting the patients where they're at and I'm meeting their families where they're at. So it's the same thing. It can be used professionally, clinically, but it can also be used in our personal lives. And it's something that I've started to use. I don't use it all the time because it takes time to go through all of this, but it is a model that has helped me kind of process things where I'm like, that could have gone better or that was really hard for me. I now have a focus in oncological rehab and when I have discussions, I'm often sitting at the end of the day kind of thinking around like, wow, this is challenging and these are vulnerable families wanting to hear some anticipatory guidance and how can I do better tomorrow when I show up for them? And I often go back to this in terms of how am I feeling about this now and how can I turn this, change the thought, change the feeling, that's then gonna change my action and change my result. So we wanted to finish with a poem, which is by Emily Dickinson called Hope. Hope is this thing with feathers that perches in the soul and sings the tune without the words and never stops at all. And sweetest in the gale is heard and sore must be the storm that could have bashed the little bird that kept so many warm. I've heard it in the chillest land and on the strangest sea, yet never in extremity. It asked a crumb of me. So with that, thank you all so much for allowing us to be in this vulnerable space and we'd love for anyone to come up and share things that have worked for them and just thank you all so much for your time. Thank you. A few years ago, we created a special issue in the Journal of Pediatric Rehabilitation Medicine on Moral Injury, and it coincides with Physician Suicide Awareness Day, which is September 17th. And Jolene Brandenburg and Erica Elise and Renat Sokoff and I believe there's one other special guest editor, and forgive me for blanking right now, whoever that is, if you can share. Raji. Raji, yes, Raji, who has, she has a special credential in lifestyle medicine. And so I want to invite the three of you, this is just incredibly moving, and you're all so articulate, much more articulate than I am, to write something for the journal for this special issue. This is something that really needs to reach out, not only to this audience, which is very important, but around the world. You know, the journal is circulated around the world. It's open access. That means that anyone who has internet access can access our articles now, which is wonderful. And bravo to all three of you. Thank you. Thank you. That means a lot. I know everyone's busy, but we'd be honored to participate in that. We'll talk after this. Wonderful job, all of you. To know you all on a personal level and to hear you today is very special. I'm just grateful to know you. What I would say, the common theme that I noticed with all of y'all is that the institutions where you were when you were going through these times was the key component to what allowed you to take what you needed. And I think if I can take anything away, you know, similar to y'all, we're going to be selfless. We're going to do what we need to to achieve our career goals, but really focusing on what the knowing the institutions so that if I wouldn't do it for myself, perhaps, but if someone were to come to me, I think this has hardened my resolve to understand what resources are out there. Yeah, I think that is so important. And I actually ended up in a random conversation earlier today with a medical student who was we were talking about burnout in general, and they were wondering exactly how to talk to people while interviewing for residency about what resources are available. And so one of the things when I because I didn't disclose anything I went through, honestly, I don't think anyone really knew until people were like, why are you doing this talk? So I had to explain why I'm part of this talk. But so one of the things I did when I was interviewing, and I have no idea if this is right or wrong, but I just tried to phrase the question as to like, has anyone in your residency ever had anything happen that made it so they needed time off or needed extra resources? And how was that dealt with in the program? But I think it's also important, whether you're the interviewee or the interviewer, making that conversation allowable, and remembering not to judge because it is really important when you're choosing where to work, whether it's for residency or long term, knowing what resources are available, and knowing how to access those once you're there. So thank you. I think that despite this being the right thing, we still live in a very ableist culture and so protecting yourself is really important. I'm glad that you mentioned FMLA. So making sure that your FMLA, if you're out practicing, covers your productivity. So this was something at my institution that was not a thing. So when I got pregnant and realized that my productivity was getting docked, and I said, listen, I have FMLA, what you're doing is illegal. And that got that changed. So making sure that your institution recognizes that FMLA covers everything from when you're gone, and doesn't penalize you for taking that time. And honestly, taking a page from the maternity and paternity leave, this is something that we know how to do, not well, but we know how to do it. And so understanding, extending residency, extending fellowship, being flexible with those sorts of things, this is stuff that people know how to do. And so being able to work with that. The other thing that I would proffer is really have a good understanding of your disability policy, whether it's a private policy or through your work. This has come up with a friend of mine who was unfortunately a victim of gun violence, and her work provided her policy. So she can be redeployed within her institution, but she can be redeployed as a janitor, and then doesn't get disability payments. And that's, so just understanding how that disability policy works. And I think it was very eye-opening just to understand that from her perspective, but also understand that that's what our patients are dealing with as well. Hi. My name's John Lee Banks. I'm a PGY3 at UPMC. Thank you for sharing your vulnerability with us. This is just incredible. As someone with a disability who lost a parent in college, and someone who lost my SSRI, this was all very wonderful. I have two questions, one kind of follow-up to the other. Because of my life experiences, I tend to get involved in these conversations with folks. And one of the questions that I have for y'all is, you talk a lot about disclosure, and almost lack thereof. I think it's a very delicate balance when it comes to trying to find what to disclose in a way that is not a sob story, in a way that does not feel sorry for me, but also is a way that I'm not going to be an impediment to this program, or I'm not going to be someone who's described as a difficult person to work with. How would you recommend that a med student applying to residency, or a resident applying to fellowship, do so? How would you empower them to do so? And then, on the corollary, if they do that, unfortunately they don't always get a positive response. Sometimes they get shut down by the institution, and that creates this fear of being vulnerable again. How do you encourage them and empower them to try again? Great question. I think it's an important question, and I think the first answer to that is for everybody to just be genuine with your response. Whether your story makes you feel sad, or makes you have a certain emotion with it, that's you, and it shouldn't be judged in any specific way. I think there is a drive or a nudge to turn that story into something positive, or to have a flip, or to have something there, but I think what's more important is that you are showing up as your true self, in your personal statement, throughout your entire application, and on your interview day. I think that has more value than something that anybody can kind of piecemeal as saying, okay, I don't really know what this is about. It's more important to be truthful to you. In terms of how it's received, I think it's important that you have that, and you talk about what you're doing with it. I think all of us, in our pieces, shared what we felt comfortable with, and when we didn't feel comfortable sharing, we started to talk about what we are currently doing, and what we can add value to, and what we're trying to bring to, whether it's to the medical school, to the residency, to a fellowship, to the attending position, whatever it may be. It's more than just the moment or the thing. I think the last thing I would say on this point is, nothing needs to be an identity unless you prescribe to it, so this happened to you. We all have things that happen to us, and that doesn't mean that you need to identify with it, and everybody else needs to know that identity, or if you do identify it, again, it's up to you to disclose if other people need to know that identity, and either way, it's okay, is kind of what I would kind of leave on at that point. Yeah, and similar to that disclosure point, I think it's holding your cards close to your chest, and then playing each one as it needs to be played. For example, dealing with the family health matter, saying that you're a primary caregiver for a family member, it's probably, it's different for everyone, but that's probably fine, but then, like, saying that I have to spend, like, 100 hours a week being there, or being there, like, 24-7 for my family member, but I'm also planning on doing a surgical residency where I need to be at the hospital very often, that might not jive as much, but you could leave, in my opinion, you could leave the second part left unsaid, say the first part, say I'm a primary caregiver, and, you know, that helped inspire me to do this specialty because X, Y, and Z, and then you decide on your own, do I reveal the other part, or do I decide, you know, is this the right place for me, or is this going to affect what I am doing? And then in terms of physical health, I think that disclosure is also important to you, and in terms of, do you think, as Dinesh said, is this part of your identity, like, will this, is it important that you state it, or is it, again, something that's part of your own personal story, but it might actually not really impact your residency and stuff, and you ask questions similar to what Megan was saying, and then you play that card if you need to later on, or after you match, after you get accepted, then you tell them, by the way, just so you know, I have several appointments that I need to go to each year, but those are your cards to play, and, you know, to me, like, I would hold those until afterwards. Yeah, and I'll just add, I think, especially, like, if you're someone who's struggling with mental health and trying to figure out how to disclose that, I don't know, for me, it was different than disclosing, like, physical health stuff, which is probably a me thing, but I tend to do it, like, situationally, so I think a lot of the ways I talk to patients or things I ask patients is probably a little different as a result of what I've been through. We have a lot of patients who have PTSD, like, are in these terrible accidents, and they have problems sleeping, and so, like, a lot of times how it comes up at my work is someone's like, well, why would you have asked that, or how did you know to talk to a patient like this, like, why are you giving our patient breathing exercises or telling them to use lavender scents or, like, whatever it is, and so then I open up, so a lot of times, I usually, like, when I get questions asked, I take that as someone cares, and then I open up, and then I play my cards close to my chest, and I choose, like, the wording I use to open up to them, and sometimes it's like, oh, I was in a shooting, and I had a hard time after, and sometimes it's like, no, this was my situation, and this is, like, how much I struggled, and then these are the resources I use, but knowing who you're talking to and also understanding, like, we're in a field full of great people, and a lot of us, like, are in this field because we love people and want to help people holistically, so I think we're in a special place where we get to kind of tell our stories a little more and be accepted still. Thank you. Was somebody on that side going, or? Yeah, yeah. Wonderful talk, guys. This is really great. I just wanted, what you were saying kind of made me think about a few things, like, one being on the topic of disability insurance. If there are any, like, med students and residents in the room I would like highly recommend that you get like an own occupation disability insurance plan that's like private outside of your work for those reasons so you could be protected and usually when you're in residency you can like forego some of the health screenings and blood work and stuff like that that you might have to do otherwise and it's a good way it's good to get it done while you're young and you know hopefully healthy and not having other things going on because once you start getting older and having medical issues then anytime you get try to get a policy they are going to exclude any of those conditions that you might have had pre-existing I also think you know what you guys were just saying with our field how we're I think hopefully a little bit more accepting of a lot of different physical or mental challenges you know we were joking about it before from the from dr. Flannery's talk how he you know said he chose ophthalmology because he like likes to sit and so I I resonated with that because I also like did not become a surgeon because I like to sit also and and it was and I I remember having a lot of back pain during my surgery rotation with the prolonged standing despite trying different shoes and and all of that and I was just kind of miserable the whole time and you know and then I was on my pediatrics rotation which again you think John Pete's people are going to be more friendly accepting things like that we were on rounds for a prolonged period of time as a you know as a med student and I was still having you know some back pain from prolonged standing and I kind of leaned against a stool that was nearby as we were rounding and I'll never forget because the attending in front of everybody you know stared at me and said are are you pregnant or ill and I was just like so taken aback that he would like ask me that and you know in front of the whole rest of the team and then you know pulled me aside to like talk to me about what was going on and I didn't even know why he asked it like didn't even occur to me that it was because I was kind of leaning half sitting maybe that you know it was like that was such a problem I was sort of like instinctively like focusing on my own health and well-being but still participating you know in everything but it was I just bring it up to say that like you know these it's still out there this like where people will just say different things and and most of the time not even realize that it's you know because I really I spoke to him about it afterwards and it it seemed like he didn't even realize that it was like a problem so I guess like I I think about that now as an attending just making sure to like really choose my words carefully and and like like you said bringing not bringing up things in groups like talking about it privately yeah I think what something that you're kind of hitting on is like the art of calling in rather than calling out right and like finding that time to really bring some somebody in whether it's somebody saying something that was inappropriate or you all on your team during rounds you're noticing that a parent says something that just doesn't sit quite right like take the moment to call it in and say like hey this didn't sit well with me how are you feeling about that or this is how I kind of received that is that you probably didn't intend that or anything like that but can we just chat about that and I think that's the way to approach this in a peaceful manner that kind of breaks judgment or any kind of punitive feeling around that and I thank you for sharing that so I actually really appreciate that you guys did not put the onus and stress on individual resiliency I have experienced a lot within these categories and I've had the blessing of having really supportive institutions and I've also had the deep struggle of actively toxic institutions that were more harmful than helpful even when I was vulnerable with them I think there is a large push in medicine to make this an individual problem when it is a systemic problem our education system is inherently inhumane residency is inherently inhumane it is a problem physicians are killing themselves and this is not something that an individual can fix for themselves it is something that we need to look at systemically as institutions if we want to continue how do we not kill our students and I think it's actually you guys were like oh yeah we're not talking about resiliency and I think that that is incredibly important especially at a conference like this is we need to be thinking about how do we address this because it is an us problem it is not a you problem and I think that that's just very important and should be our attitude in the way we think about things it's not an individual issue it is a systemic issue in all of medicine yeah I think I think those are great great words everybody said to I residency's fellowships have always been the greatest slave slave labor market in the world forever and it's it continues to be that way so that's been at least the last 40 years of it or more a couple good points that and it needs to change and still the the point of pointing out mental health on your credentialing and your state licensing's your reapplications all those forms and such you know I've had the privilege of serving with the American Board of Medical Specialties also a half dozen years or more we went through the state-by-state credentialing's and almost 30 40 percent of them still have mental health separated out from from health you know is there a mental health reason why you can't provide the services that in a safe competent way and and we're trying to get them all changed to you know is there just a health reason why you can't provide the level of service you need to and get rid of the word mental I think it's mostly cleaned up but there's still a lot of credentialing maybe at your institutions or state that you could read through and make sure they get rid of the mental in front of the health word on those boxes you have to check off up and such maybe we can all clean up our regions in that regard and finally I've had the privilege of being in in the army 24 years before combat tours in the Middle East and we take care of soldiers on both sides of the fields and the whole village and tribes and but you know people would a lot of stuff happens a lot of post-traumatic stress disorder as Megan talks about here it's very common the one of the biggest principles was trying to stay engaged as close as you could to the battlefield or as close as you could to the theater be and not completely step away from that it seems to even get worse if you step away from it too far you may never come back into the field at least look like Jeremy wanted to be participating somewhat in your fellowship even even in the midst of getting yourself healed with the testicular counselor and maybe making that was somewhat of a blessing that you kept somewhat engaged during it all but I've seen it go bad the other way when people step completely out and then they're they're pretty much done with that field but you make your own choice but when there's a doubt as close as you can stay engaged up whatever distance you need is probably a good choice if you're in doubt about it I just want to say you know you're talking just in regards to a lot of all these things that go on and in regards to being you know your fellowship what do you disclose what don't you disclose and I want to first thank you all for being so vulnerable because you know all these different three things have what you all talked about touched my life you know in very many ways and I recently had very severe accident and you know you talk about just about the PTSD and you're you're losing somebody and your diagnosis and all this and trying to work through it and I'm a nurse I'm not a doctor but you come yeah provider in some way but it is to acknowledge all those different things you you go through and I think a lot of it is reaching out for health and acknowledging that PTSD and being able to say yeah I really do know like this like the physical part is to me was the easy part to get over the PTSD is horrific and I think just learning to reach out to your HR department and asking and and you know talking when you have your benefit plan because you're probably all enrolling in your benefit plan right now let me tell you I was so grateful in March when I checked off accident disability I'm a single parent right and and you realize oh thank nobody talks to you about this nobody says anything and you're like oh my god thank God it was in my back pocket but I will say to all of you doctors in the field when I sat in the doctor's office and I said you know my doctor in Austria this because this happened overseas by the way have travel insurance helps immensely is that I remember him going into this appointment and I said well the doctor in Austria said I could go back after three to four months and and he looked at me and he goes okay you can be a hero he goes but I don't think you're ready and what do you really want to do and when that physician looked at me and said that those words what can I do for you to be successful in this recovery I was shocked and those words means so much because you're like I'm not alone I'm not crazy I'm really you know and yeah you might be able to say that three months on the paper but you might need longer and just not saying well you're going back in three months it's what do you need to be successful so I think those were the words that really helped a lot and there's an EAP program through your work probably hopefully and that was a you know those are great resources and really just tap I tapped into my HR department like I'm having problems I mean the issues I got from the insurance were I think the most traumatizing to me I mean really just trying to call an insurance company was you know they're telling you it's not a medical emergency therefore you're not they're not going to pay any of your bills you know and trying to work through so there's people out there and reaching out and networking has just been huge so and thank you all for being so vulnerable it's really hard to share sometimes thank you all for sharing we have a and appreciate all your comments we have one comment when in residency at that time pregnancy was not formally addressed my PD interface with the board made me feel supported and gave me the time I needed thank you so much for sharing your story and giving us that extra tidbit too because I think it's easy as providers people ask for a timeline and we give it and it's so important to remember to bring in the humanity to every patient we see so thank you so much Does anyone have a gavel to wrap up PEDS Advanced Clinical Focus Day for the first time? Is that your job? Oh. Okay. Well, congratulations on the first ever PEDS Clinical Advanced Focus Day.

mental health

medical training

testicular cancer

PTSD

caregiver

healthcare support

systemic change

resiliency

stigma

empathetic environment

supportive structures