Panel Discussion: The Wellness Think Tank

Panel Discussion: The Wellness Think Tank



good morning everything everybody how are you all doing good glad we're here today to talk about the wellness thinking by based upon academic life in emergency medicine this is a organization that we created and we want to talk to you about how and why we got to where we are today about a year after the idea was originally constructed the issue of burnout wellness resiliency is an important issue in medical training and it's an issue that many who are outside of medicine don't necessarily know a lot about so that's what we want to talk to you about today what are the issues why are these words burnout wellness resiliency associated with medical training today what were the issues and what were the solutions that we came up with we also want to make this interactive and throughout this we will have times for questions and we definitely want you to feel free to ask us any questions you may have as well we hope to make this a back-and-forth dialogue as much as possible ultimately we want to shed light into the problem give a glimpse into those who don't know about medical training and what it's like to be a graduate medical learner and come up with better solutions perhaps than what you have even come up with first I want to introduce the panel that I have with me starting with Arlene hi everyone my name is Arlene Chung I am a practicing emergency physician in New York City and I am also one of the assistant residency program directors for the Mount Sinai emergency medicine residency program good afternoon everyone my name is Shaheena Braganza I am an emergency physician from Gold Coast health in Australia and I've also recently finished up a role which is a director of clinical training looking after pre-vocational doctors my name is Nicole d'Italia my practicing emergency medicine physician at the Mayo Clinic in Rochester Minnesota and again I am making ty Joshi I work here at Stanford University and one of the emergency and medicine doctors involved with resident education but also medical education throughout this talk we want to share our own stories of burnout so that it can perhaps give insight as to why we are actually personally invested in this issue as well and my story I also was trained in New York City at a County Hospital in Brooklyn and my training was four years it was a pretty grueling experience from day one it's ER off kind of already on the go and of course my fellow residents understood what I was going through but that really is a very small subset of people compared to my everyone else that I knew and that included my husband my parents didn't quite understand what I was going through and I realized that I had a problem when I would come home and try to explain the situation whatever I had experienced that day with my husband who's not in the medical field I tried explaining him the emotional rollercoaster I went through that day based upon the patient's I had seen the workload what it was like to work with consultants perhaps difficult encounters and more than anything I just actually wanted him to just listen and not to say anything back I never got that I always got words of advice none of which I wanted and it became actually so frustrating to the point where I stopped talking to him and we hit a point in our relationship where it actually challenged our relationship and there was a good point where I saw that perhaps may not be able to move forward because my experience was so difficult I felt so unable to talk to him about it and of course we moved on persevere to graduated we're married we have a child and things are better now but it's this issue of loneliness having no one to really talk to that's just a small subset of the whole issue of what leads to burnout and what we hope to explore here today so I'm going to turn it over to Arlene right now what if I told you that there was a disease out there that only affected smart capable compassionate and motivated people what if I told you that this disease was almost always fatal killing almost a hundred percent of the people who had touched and that the symptoms were completely unrecognizable to most people if I told you that and the CDC knew about that they would be on top of that in a heartbeat but there is a disease like that or maybe not a disease in the true sense but certainly an illness out there and it's physician suicide and one of the things that we hope to do today is to shed light on this issue I am so I first I've moved to New York City in 2000 and 2014 shortly after residency and I had had a passing interest in wellness while I was in residency and I was part of their Wellness Committee there and to be honest it was mostly just organizing social events and resident gatherings which was which is fine which was great and personally I you know yes I thought residency was hard but I got through it and I survived and I said okay I am leaving and I am going to New York City to live my attending life and within the first couple months of arriving there this article came out in the New York Times which was the first sort of realization for me that this type of problem existed and one of the things that it did for me in reading it is that I came to realize that there is a problem in medicine and it's a problem that we're really I think ashamed of and we don't really want other people to know about but there are these things that keep happening and they're going to keep happening unless we address the problem as the author writes there is a strange machismo that pervades medicine doctors especially fledgling doctors like me feel pressure to project intellectual emotional and physical prowess beyond what we truly possess as soon as that MD is appended to our name in May our self expectations skyrocket as if the control of the degree were an enchantment of infallibility the internal pressure to excel is tremendous after all we are real doctors now but there's a there is a spectrum it doesn't just start with a happy college graduate and then all of a sudden become a who's on the brink of committing suicide there is stress certainly which leads to burnout which leads to depression which then leads to suicide this graph is just demonstrating data but I mean there have been there have been several studies have been published since looking exactly what are the prevalence rates of depression and suicidality in our medical trainees and it's enormous if you're not aware that this is a problem if you look it gets up as high as over 30% and can you imagine if that 30% went on and no one recognized that there was an issue and they went on to become physicians and one in three physicians was suffering inside without without being able to tell anyone and with having this sort of shame that they were struggling with this alone and in fact it's true if you look at studies that are beyond even medical trainees this is a study that was done in a population of us physicians across the spectrum of career so from early career to late career across all different specialties and if you look on average the average burnout rate for all physicians is almost 50% emergency medicine has the dubious honor of being number one at the top of this graph if you see that little grey line that is shooting way above everyone else that's emergency medicine which is a specialty that I practice in so clearly this is an issue that's important to me as well and so I you know I got really involved in wellness right I I personally you know I had my struggles and residency I wouldn't say that I ever suffered from burnout but I really felt compassion almost more for my fellow physicians and I did for the patient's which you know it's our job as doctors to take care of the patients and we will take care of patients but the question that I had is we aren't you know we're so dedicated to patient care but who's dedicated to our care well we have to be dedicated to our own care and so I became involved in wellness organizations and in promoting physician wellness and and the culture that I was exposed to the first few years in New York following that first summer of 2014 was was really encouraging I was like we're making strides we're making progress we're doing it and and then that happened and then August 17s happened one of our deans David mullet had written this perspectives piece in the New England Journal I think he described it well why this keeps happening why doctors are committing suicide it's because there is a culture of performance and achievement that for most of our students begins in medical in middle school and relentlessly intensifies for the remainder of their adult lives from their very first shadowing experience to their foray into the lab from high school AP classes the GPAs and the MCAT with helicopter parents violins varsity soccer medical school rankings licensing exams and the residency match we never let up on them and it's killing them so why do doctors commit suicide we commit suicide because there is intense pressure to succeed there's intense pressure to excel from a very young age there was a very tiny margin for failure and there's so much shame and stigma surrounding it but what we hope to do is to pull back the curtains and to show you exactly what goes on inside and hopefully to shed light on this and to create a solution together and that's why we think that this presentation is also so pertinent to have at this conference where it's not just about medicine but about the entire community coming together and looking at how we are training pulling back the curtain as arlene says so I want to take a moment if anybody has any other thoughts besides what Arlene has mentioned about the topic of why doctors commit suicide and any insight you may have as to why that happens hi so I'm actually a first-year medical student at Mount Sinai so nice to meet you and I'm sure we'll talk after this so just regarding this topic I actually studied positive psychology at Penn last year I got my masters in it before coming to med school and so I did a lot of research into this topic I've heard everything from you know medical I don't want to reach out for mental health resources because then you know I'll have to check that box on my licensing exams as I continue to get licensed and like you said the stigma fear of you know thinking that you're compromised and unable to treat patients and I think it's also a lack of emphasis on this in our medical education as I'm sure you're addressing like we are so focused on taking care of patients as you said no one's helping us take care of ourselves and our institutions need to support it it can't just be up to the individual so we're making you know a lot of changes and I look forward to the rest of the talk but this is so important so thank you I think it's also important to have it at a conferences like this so that we can get input not just from the doctors dealing with this supposed to doctor problem but also from the patients and the industry themselves because everybody really is impacted from having a physician who may not be mentally stable and who may be suffering from suicide so I work on the educational side of things and I'm just curious how you would recommend or what you would recommend in terms of implementing Resident wellness and resiliency into a residency program I know that you know for us there's only so much time we can allocate to it so we have ice cream rounds where there's a session for residents to discuss what's happening I don't think we do it as often as we should like once every kind of term four or five months but I was curious what your institutions do there I think that's what the rest of this presentation will be about our solution that we had come up with the wellness think tank that our Nicole will expand upon once we get there but over over all lies the answer is pulling together national resources and realizing that institutions have solutions but nationally if we can pull together I think we can come up with something great so I'll take this to move on to Shaheena she's going to talk about this issue from an international and also an organizational perspective Thank You Nicky my journey into wellness began about 15 years ago when as a second-year resident I experienced a version of burnout in brief it was my boss who rescued me at the time most impactfully with the words I've been there at that time in Australia the attitude of the medical profession towards wellness was that it was at best an afterthought and at worst an issue that might have been considered and indulgence undertaken by those in the profession who what's clearly not busy enough doing the legitimate work of being a clinician and I suspect that you might be able to relate to that as well beyondblue is an organization in Australia that researches and supports people with depression and anxiety and in 2012 they conducted a survey that in my opinion really heralded change and progress for us in Australia it was a national survey of the medical profession and their respondents numbered aprox medli 11,000 doctors and 1800 medical students off its most profound findings this is one figure so the figure on the screen here shows a comparative analysis of rates of psychological distress in the left-most graph is the rate for doctors in the middle is general Australian population and on the far right are other professionals which includes other health professionals as you can see the rates of psychological distress in doctors is double that of a general population and about ten times that of other professionals there are very similar comparative data for all the components of burnout and there's even more comparative more startling comparative data for rates of suicidal ideation all of this has played out for us in the last few years where we have had clusters of suicide in physicians and in trainees and this has really drawn the attention of our community and our media and the medical profession I feel is now in a position where it must act in a way that is substantial and that is meaningful in its closing statements the beyondblue executive summary stated that doctors must resolve their stigmatizing attitudes towards mental health because their failure to do so not only affects their mental health but it affects their ability to care for their patients and it's not only affects their mental health but it also affects the community's attitude towards mental health and for Petula's the stigma that comes with it and so these are some of the things that we have done in response the Australian Medical Association has made wellness a top 5 priority for the next 5 years and as such two examples of how it is acted are that it is enhanced its doctors health advisory service in order to make it more accessible and more relevant to what the medical profession me another big issue that it's working on is that it's lobbying to change our mandatory reporting laws in all states except for one in Australia currently if you are a doctor and you seek medical attention for a mental health issue the treating doctor is mandated to report you to our regulating body because your mental health condition might impair your ability to look after patients and so that compromise of your registration and your ability to work is an obvious barrier to seeking help our own Australasian College for emergency medicine middle of last year conducted a very large workforce sustainability survey and its findings very much parallel those of beyondblue predictably and are and as Arlene has demonstrated as well burnout rates are high in emergency physicians and in trainees and a significant number of respondents reported intending to leave the profession within the next ten years the college is now working on a strategy and implementation in order to address this around Australia several hospitals have taken the initiative to form their own programs one that I particularly admire is run by a health service called Monash health on the bottom right of the screen there and their program runs by the slogan no junior doctor will struggle in silence Monash care is an initiative that's completely initiated by hospital executives and designed to support junior doctors and examples of some of its arms other they've got a dedicated well-being officer they have mentorship groups and they even have a perinatal group that supports young doctors male and female around the time of early Parenthood where I work at Gold Coast health in our emergency department we are working to embed a wellness program in our IDI that is focused around mindfulness I would love to tell you more about this at our learning lab later this afternoon at five o'clock we even have chocolate biscuits we are trying to take the approaches being proactive than reactive and I strongly feel that we need to change our frame from helping those who are struggling to a culture of positive growth whereby we just create environments where everyone can be nurtured and everyone can thrive whether they're struggling or not or not here's a little bit of what I've learned in the last few years of supporting junior doctors firstly they are not simply us 10 or 20 years ago Millennials are uniquely different in their characteristics they tend to engage in group think and operate almost with the collective consciousness and as such I think a model that's based around peer support is most likely to be acceptable to them and accessible secondly they are completely wired to the internet whatever it is they need input for whether it's how to conduct a procedure or how to manage migraine or even whether it's how do I manage my psychological distress their go-to is the Internet and that's why I think an organization like a Liam and what it's built around a think tank which you'll hear about in a moment is perfectly positioned to support junior doctors and residents and my final observation is that whatever we build together in order to support our junior doctors must meet the needs of the end user in my experience junior doctors tend not to follow traditional avenues of health such as human resources or what we have in Australia and is called the Employee Assistance Service unless we direct them to go there because they've made an error or because a specific issue has arisen and so junior doctors must really robustly inform whatever it is that we build from here having said that here's my call to action it is incumbent upon senior clinicians to initiate influence and sustain the discourse and action in the sphere Larry Chu in his opening address this morning described our role as being the Shepherd who guides the patient through the most vulnerable period of their lives our other vital role is that we are also the shepherd who guides our residents through the most vulnerable periods of their life not just professionally but personally I feel that we are the people in the position of power and influence and we are also the people who lack the risk that our junior doctors have if a junior doctor were to voice a concern they risk their career opportunities and we don't carry that risk it's also important to understand for us I think that we kind of created this in the first place or we're certainly perpetuating it firstly we aren't necessarily well in the first place we don't really look after ourselves in terms of wellness beyondblue found that rates of burnout psychological distress and suicidal ideation decreased as we advanced in age and in seniority but I feel that that's less that because we develop intrinsic wellness and more because we just develop better control over our environment as a senior doctor if there's a particularly unpleasant task to be conducted we can defer it we can even delegate it the other thing is that our colleagues become more tolerant of what might be our dysfunctional behaviors as time goes by attributing them to our own idiosyncrasies oh yeah we all know Bob you know he's a bit aggressive abrupt unapproachable but that's just Bob he's a great procedure Alice and this attitude not only disregards the effect that Bob has on his colleagues but in his junior colleagues but it completely dismisses the fact that Bob might have some significant struggles himself we tend to wear our unwellness like a badge of honor even if you're doing the job properly you're going to be overworked overstressed and fatigued and we don't model the prioritization of our own wellness to our juniors and as such we are then responsible for the culture not just within our profession but within our specialties we are now in a position having inherited that culture from those who preceded us we're now in a position to make a conscious decision of whether we allow it to perpetuate or whether by leadership we just change the immediate environment around that simply by inviting and encouraging the conversation on wellness perhaps simply by saying the words I've been there and so my closing statements in this international chapter of the wellness story are that this is not an issue that's confined to one part of the world or to one specialty it's a global issue and if it were infectious it could be called a pandemic there are various groups working on this around the world I think it's vital that we connect with each other because by doing so we not only support each other but we lend credibility to each other and together we might convert an issue that might be considered and indulgence into one that is not only legitimate but one that is absolutely critical so with that we wanted to talk about what we actually did so I am one of the board members of academic life and emergency medicine which is a blog that was started in 2009 by Michelle Lin who is an emergency medicine physician at UCSF this blog started out as a repository of clinical pearls as she would develop on her shift that she would then publish as blog post as a means of storing it and it has quickly grown since 2009 to really be an academic hub for emergency medicine trainees and also turned into a community and so academic life turned from a blog into a community over the years we have tackled many issues mainly within medical education how to best share procedural tips how to best learn the latest breaking in the best ways to practice and treat pneumonia for example one of the things we then started to tackle was training and a few years ago we decided to gather chief residents nationwide into a think tank of its own called the chief resident incubator and from that we actually began to find a few stars that were rising Nicole is one of those future leaders in emergency medicine and for Nicole wellness was an important issue and so we took that academic life our passion as you can see is to lead as a respected institution in advancing education professional development and community building globally using digital technologies initially the blog and from their Twitter Instagram SoundCloud in emergency medicine and other health professions our niche is innovation education and community building in health profession education so from this working with Nicole and a few other experts we developed the wellness think tank the wellness think tank our mission is to create a diverse community of residents and educators who collaborate innovate and advocate preposition wellness from the ground up this grassroots initiative tackles reson issues such as preventing suicide and burnout enhancing resilience and promoting overall quality of life our ultimate goal is to catalyze innovative and positive change at the individual institutional local national and international levels so before we get into really the nitty gritty about the program which is what Nicole will be going through I just wanted to take a moment to think about what we're really doing is taking digital technologies in the internet and taking that and tackling this really important topic of burnout and suicide and so one thing I want you to think about as we move forward for the sake of time is is the online space really the most safe place to have this type of really deeply personal conversation that most people have individually will feel very reluctant to share with their friends their supervisors and now we're asking them to share this internationally using the online world which can be discoverable really by anyone and at anytime regardless of your privacy settings so as Nicole describes well we've come up with and the safety measures that we put in just keep that thought in mind so as Nicky mentioned wellness is a really important topic for me as a third year in a chief resident I quickly during the middle portion of my third year hit a burnout point I was the definition of burnout I was depressed and there were definitely days where I rather would have driven my car off the side of the road than to show up to work that day it was a pretty terrible place to be and as I moved through the rest of my residency and into my first year of practice on my own this group kind of came together with other individuals who were also concerned about wellness and we decided to again form this group using the model that the chief resident incubator had used pretty successfully to try to do the same thing to tackle wellness to start our leadership board included again folks who were very well versed in using these virtual digital communities in addition to our lean in myself who really kind of handles a more day-to-day and project development in addition to us there are five other faculty mentors and five resident mentors that are located all across the country so we've got very good representation across the u.s. and also faculty mentors and resident members from Canada to start you know we try to figure out who we wanted our stakeholder to be and we really wanted to focus on emergency medicine residents we wanted to kind of get in at the ground level of Education where a lot of people tend to build and develop the techniques that are going to use throughout their career to develop and maintain their own wellness so we really wanted to kind of pick a stakeholder group that was a little more grassroots feeling and at the start of their medical careers we offered this program free for every emergency medicine residency in the US and Canada and programs were allowed to submit one to two residents that they felt were interested in wellness to serve as an ambassador or a wellness champion from their program as you can tell by the map we've got some fairly good representation across the US and then again folks from Canada the platform that we use to communicate a slack for those of you not very versed in what slack is it's a cloud-based online collaboration and communications tool that's used by a lot of companies to address what Nicky brought up about safety and is the internet you know a safe place to kind of conduct this sort of business slack is pretty useful in a sense that it allows folks to communicate directly by a direct messaging we could also communicate via locked channels and we were also able to put in a plug in so to speak under the ask think tank channel where members could ask a question or ask for advice to the rest of the think tank completely anonymously so we've kind of found this to be a pretty good way to try to communicate and collaborate online while maintaining some anonymity or creating an environment that felt somewhat secure when looking for partnerships and corporate partners we were able to find some companies and corporations that also had a vested interest in wellness we partnered with us acute care solutions which is an IDI staffing organization in the US we were able to meet with them in person at one of our large meetings in the fall and they expressed a very big interest in physician wellness especially since they employ a lot of emergency medicine physicians they were interested in kind of developing with us and learning what they could from us to pass along to the physicians that they employ to keep them well in addition we've also partnered with a couple of food delivery organizations where you gets a meal prep in the box chef in peach dish collaborated with us to try to provide some of those options to our resident members because you can imagine for a busy resident eating healthy food can be pretty difficult in terms of the nuts and bolts of the think tank and and what are the actual solutions we're trying to come up with we started by partnering with what we call wellness strategists outside of the field of emergency medicine to try to provide an outside perspective different than what we were just coming up with ourselves we've partnered with Jason Brooks who is a performance psychologist out of Canada and he's worked with us as a group and with individual members I'm really you know using performance psychology to combat stress we've also worked with vom D who you may or may not know but is considered to be kind of a thought leader in a sense that he's trying to work towards disruption and revolution revolutionizing medicine as its delivered as a system currently and then we've also been able to work with James Dahl from the white code investor to focus on fiscal responsibility and financial wellness which is also important for physicians something that we're not always the best at in addition to that group and some others that weren't on that screen such as Shekinah we've worked closely with her we've also partnered with a group of experts in psychology and psychiatry as we felt it was important to utilize our colleagues from that side of things to talk about mental health and how it impacts residents to talk about issues such as substance abuse to talk about how as residents can you increase empathy day to day as we felt like it was important for them to kind of bring in their perspective as experts from that field and as providers who treat you know med students and residents and do your faculty from here we kind of want to ask the question to you guys a do you think that it's a good idea to bring in experts outside of your field of practice to lend an opinion outside of that area and be is there an organization or is there a group out there that really seems to be getting wellness right that we could learn from not necessarily even in the medical realm so a couple questions for you guys I would say it's really important to bring people from the outside and I think of IDEO for example and the teams that they create and bringing people like taking an interdisciplinary approach because we're trained in different ways we are educating different ways so I think adding another perspective or another layer to the opportunity or the problem is really important and I think in the long run you end up with a product or a result that is more holistic and can be applied to other professions as opposed to just one hi there we go yes okay good so I work with a group called the functional medicine coaching Academy and we train health coaches and an area we're interested in moving into is supporting residents in particular but young medical providers and so the health coaching concept is one that we know can be effective for people because it's a frequent touch it's kind of a frequent light touch we can look at sort of a holistic health so that we will be talking about are you eating are you sleeping are you exercising do you have anybody you can talk to and then we can help you know brainstorm if they need more in-depth support so that's one system that we're feeling like be able to offer opportunities and an organization like ours everything is online so the providers don't have to go somewhere to meet with their coach they just get on a laptop they have a webcam the hours are flexible we have coaches all around the world that we're training now and a student coaching center so we have inexpensive coaching available for residents who don't have a lot of money as a first step and then if they connect they can certainly work with one of our alumni after that so I just kind of wanted to throw that out as a model that is very flexible to a resident schedule and to their pocketbook as well but a way of getting some ongoing support great thank you hi my input is that I think it's important to have somewhat like a collaboration somebody who knows and understands what their daily routine is like and get somebody from outside just to get a fresh perspective or for them to be able to safely in the sense without being judged they should be able to express themselves because I'm opthamologist and ophthalmology is not where you expect burnout but even on your data that you showed but it exists I just think it's not reported just last week we came across a very huge problem that we are dealing with in our area and it is heartbreaking and I also think that providing them with a life skill to mean to deal with stress that's one and number two start early in medical school we need to change our own culture on how the educators are treating the students that is I'm very passionate about it and I will really applaud all of you bringing this discussion to this conference thank you thank you let's move on to talking about what we've come up with and then we'll take the remainder questions so in terms of deliverables and what have we kind of done so far in collaboration with our strategists we have been able to record a number of podcasts which are available on the alien SoundCloud that way what we do has been made not only available to the members but outside of the membership of the think tank probably the biggest project that we're working on and what we've been doing has been pre work for a resident wellness consensus summit that is being co-sponsored with essentials of emergency medicine a conference taking place this upcoming May this is going to be a pre day consensus summit or consensus conference that I really feel and we feel is very unique because it's really the only consensus meeting that's going to be focusing on residents as a stakeholder and as those coming up with kind of the consensus recommendations from here these are the we're really focusing on some of our deliverable projects there are many emergency medicine residency programs that do not have a wellness curriculum so we have a team that's coming up with a blueprint that they can take back to the program to use and then modify to fit their programs needs in addition we're going to be looking at some data as a current survey in emergency medicine residency programs of what the level of burnout currently is and there's going to be a group looking at current technology focusing and wellness this is just a little sample from kind of one of our massive spreadsheets where the residents are testing out different apps and such related to all kinds of health-related and wellness related apps in addition to some of these apps we're also looking at and evaluating online resources for like obtaining therapy and that kind of thing for those that I feel like there's too much of a stigma in their community to go to their local mental health providers so it's a fairly comprehensive list of tasks and programs that we can give to residents to pick and choose things they can incorporate into their personal daily life again we really feel like this is going to be a great opportunity for the residents in addition a problem that frequently comes up with a consensus conferences actual representation to come up with a consensus between the enrolled participants in the think tank and also the people who will be attending live we feel like we've gotten a pretty good representation of residents again across the u.s. Canada and there will be some international residents attending so the virtual community has been a really great vehicle to get mass representation to do the pre work for this consensus summit so you know we haven't necessarily come up with the solution per se to wellness and this is going to be an ongoing problem for I think a while a lot of you brought up some great points we definitely need a culture change we need to decrease the stigma surrounding talking about mental health issues we need to not penalize our colleagues for seeking helpless they need it but this is kind of what we came up as a solution and a place we wanted to start so we really thank you guys for taking the time to listen to us today and we have a couple minutes left so we'd be happy to take any questions if anybody has additional questions this is a fabulous session I commend you all for the honesty that you've given us today about your experiences in dealing with it and also how to better improve the situation just two questions I've got for you number one many of us who are faculty who want to try and help when a problem is recognized we can try and let these set residents or trainees down but I think part the problem is we're limited because you don't have the experience in how to deal with that and the resources that we have in terms of counseling aren't available even a places that might be similar to this if resources are limited are there any other suggestions that you have when you're dealing with someone who has a stressful life as a resident or a fellow that you can provide and secondly I'm trying to become a lotta phrases when you have male trainees the way in which they handle stress may be different than dealing with female trainees and there's no male representative on that so right now I'm quite I'm not I'm not surprised to see that do you guys have any insight about how male residents and trainees and also how male faculty deal with stressful situations for trainees that our men and women respectively another question make sense I think Eileen you want to check along okay so I can tackle the first question one of the benefits that I think we saw in creating a virtual community was exactly sort of the problem that you mentioned where there are pockets in the country where there may be no local resources available so we felt that the one strengths of having something that's utilizing all the technology that we have available is that you could potentially as a resident reach out to another resident who lives across the country and who else is there that is better equipped to understand the struggles of a resident than another resident which is primarily why both the constituents and the stakeholders of the think tank are the same so we really hoped that they've taken sort of bonding with each other and meeting people from across the country to really merge their interests I mean as far as you know the the individual resident would you know the person that we're really this is like this is the person that we're doing all of this for that's a hard question to answer and you know I do a lot I mean I work a lot in the Wellness sphere and I really hate to say that I don't know that we've come up with a fantastic solution yet I really think it lies in culture change and I think the broad based effort like the think tank is a really big step in the right direction of culture change in regarding your second question I'll turn it over to Nicole for a second to talk about our distribution but our leadership actually does include a few other men on the field and I think this also speaks to a culture shift as well and one of our biggest advocates and the reason why this group was put together was dr. Chris Doty who's the program director at University of Kentucky their program unfortunately suffered a tremendous loss about a year ago so I don't have any specific advice to address males versus females when they're coming to you with an issue or problem by the initial advice I guess would be to try to find a person to reach out to them that you feel like would resonate with them but we've got other males on the faculty and the resident leadership and a program half of at least half of the strategist that we've worked with have been male as well so there's definitely interest there but I don't know I know what the right answer is in terms of trying to address but I agree there's probably some differences my initial thought would be just to find the person to work with the resident initially that you feel like would resonate best and then in terms of your first question there are a lot of resource-poor kind of areas and even if you work at an academic institution your mental health resources for residents may not be great most organizations should have an Employee Assistance Program but some people don't want to use that and fears that they'll be stigmatized so there really are a lot of online resources you can do virtual therapy with people line and they're all licensed therapists but these aren't really resources that a lot of people are familiar with so part of what we're hoping to do is just make people aware of the resources that they can use if they feel like they're in a pinch or they just don't want to use the resources that they have available due to concerns that have so before I turn it over to Shekinah for our final thoughts we'll take one more question this is just a comment to dovetail off of what the information you just provided just that there's a pretty robust literature on male patterns of depression and female patterns of depression and maybe some flags are more obvious to us than others but the way at least emergency medicine works in the u.s. with the council of residency directors the majority of program directors are men and so and the trainees now I think we're at the point of 50/50 in terms of medical students going into emergency medicine the distribution of men and women so there is a tension paid to it for sure and a knowledge that the signs and symptoms may present differently okay thank you so much I'm gonna turn over to Shaheena for one last thought so in closing the time is now we recognize and understand more about position wellness and unwellness than we ever have before the question is what do we do about it or we can continue to do a little and to allow the status quo or we can make the decision that not just as a profession but as a community we're going to grasp this with both hands and we're going to determine to fix it firstly by empowering our residents finding the solution I feel will require intellect but more than that it will require heart the end game here is to normalize the conversation on wellness so effectively that if a junior doctor is noted to be struggling anyone from a hospital executive to medical colleague to a nursing allied health even non clinical staff member perhaps even with some careful thought a patient might feel comfortable enough to reach out a hand and ask doctor are you okay thank you very very much [Applause]

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