Hello and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director of SMI Advisor. I'm pleased that you're joining us for today's SMI Advisor webinar, an organizational consultation model to advance a culture of well-being. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credit for participating in today's webinar will be available until January 3rd, 2022. Next slide. Slides for the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. Now I have the pleasure of introducing you to the faculty for today's webinar, Dr. Gaurav Agarwal. Dr. Agarwal is an Associate Professor in both the Departments of Medical Education and the Department of Psychiatry and Behavioral Sciences at Northwestern University's Feinberg School of Medicine. He serves as the Director of Physician Wellbeing for Northwestern Medicine's Medical Groups and Director of Faculty Wellness for Northwestern University. Dr. Agarwal, thank you for leading today's webinar. Thank you for having me, Dr. Cohen. I appreciate the introduction. Just before we get started, I just wanted to highlight my disclosures. I do receive honoraria for various wellbeing presentations, wellness coaching engagements, and consultations. For our talk today, our learning objectives are incorporating, being able to incorporate an organizational culture of wellbeing in the workplace setting to improve workplace conditions and to apply frameworks that can help organize the change process for your organization. I always like to begin these talks with a little bit about what's my why? Why do I think this issue is very important? What's influenced my thinking and approach to this idea of healthcare professional wellbeing? So I spent most of my clinical career working on a psychiatric inpatient unit in a community mental health center treating serious mental illness. I think one of my biggest joys in treating serious mental illness has always been that I've always felt like it's best done as a team, with a team of individuals, APNs, RNs, mental health technicians, psychologists, social workers, PTOT, art and music group therapists and trainees and administrators. I thought that this teamwork really is what made it enjoyable and really when we provided the best care to our patients. But of course, the team also introduces a lot of system dynamics and team dynamics that we had to be very mindful about. In addition to working on the inpatient unit in the community mental health clinic, I also specialize in the assessment and rehabilitation of impaired healthcare workers, which really means healthcare workers who were no longer able to safely practice their profession. At this point, I probably evaluated about a thousand healthcare professionals from all around the country. And when I meet them, I reverse engineer their stories to find out how things turned out the way they did. I don't think they ever planned on seeing someone like me. While each story has certainly been unique, there's also this familiar pattern of work dissatisfaction and stress that preceded the usual addiction, mental health or behavioral issues that had led them to me in the first place. I decided I wanted to understand more about the role of workplace stress and I really started to specialize in a field called occupational and organizational psychiatry, which really is just a study of workers and workplaces and how to maximize the potential that each has. I've always felt like no good psychiatrist can do a talk without quoting Freud. So I was always looking for, you know, what did Freud have to say about this issue of work? And he really did note the centrality and importance of work in people's lives when he said, love and work are the cornerstones of our humanness. He's also attributed to go on to say that the capacity to work and love are the signs of good health. And based on my clinical experiences, I really felt that burnout was a direct threat to healthcare professionals because it really seemed to impact so many of my patients' capacity to work. So trying to do something to prevent our work from harming our health is really my why for why I care about this topic. As largely a mental health audience today, I suspect many of you well know the importance of self-care and how you might take steps to continue to care for your individual mental health. However, the research really suggests that a large component of healthcare professional burnout is due to system and organization drivers. And so I want to spend my time today sharing our consultative approach to working within an organization or system and to change those drivers, those organizational system drivers. And so my hope is that you can take something away today and empowered to be a constructive partner in creating a culture of well-being. The first lesson in this work, of course, is that your why, your individual why is not enough. When working with systems and organizations, you have to understand their why and do everything you can to align your why with their why. My organization's mission happens to be patients first. As you can tell, there's nothing about healthcare providers in that statement. And that was certainly a worry for me. However, as I came to understand the quadruple aim, it really, you begin to understand that we can't achieve the outcomes we want for our patients, such as better care, improved outcomes at a population level, lower costs, unless we expand and make sure that we include clinician well-being. So for me, the quadruple aim was our way of making sure that my why and our organizational why are actually in complete alignment. And now we were able to move forward together in our goal of creating this culture. If the goal is to create a culture of well-being, I think it's really important to understand what culture means and how it differs from another related concept called climate. Culture refers to how things are really done around here. The way I usually describe it, it's like what you would tell a friend who just started working in your organization about what do they need to do to get ahead here and be successful here. It's really about these shared fundamental beliefs that a group has, and they're so ingrained that people don't even recognize it there. Climate, on the other hand, is how do things feel here? What's the atmosphere in this place right now? You can probably tell it when you go to a party or school or somewhere where you're like, man, it just feels like something's heavy here, or something is really energetic here and lively and vibrant here. It's a feeling. And I think what's important to recognize here is that culture really does take years to change. It's a very slow process. Where climate is thought to be more fluid. It's a feeling after all. And so things can change from a perception perspective more quickly. We have historically wanted to focus on culture and used evidence-based ideas about how to advance that culture of well-being, including shared accountability, creating a network of change agents, really making sure we did leadership development around leadership behaviors, really creating a shared vocabulary. And overall, I certainly think that's the right approach for systems and organizations to take. However, I think as you embark on this organizational consultation model, I think one of the second steps to really understand is what is the current climate? What's the current situation that I'm trying to affect? What's the readiness for change and ability and capacity for change in the organization or system that I want to work on? I don't think I have to tell all of you, we're obviously in the midst of a pandemic. And that what we know from history is that the psychological footprint of disasters greatly exceeds the size of the medical footprint. And obviously in this case, the medical footprint has been so gigantic. And so one can only extrapolate what the duration and magnitude of the psychological footprint will be of this pandemic. I believe that part of the psychological footprint really includes this low morale pandemic that we call, that we're calling it amongst clinicians across the country, this isn't unique to any individual institution. In my experience, talking to colleagues from around the country, it's really a difficult time for healthcare professionals. And I believe it's a contagious emotion. And one that we have to really be very mindful about is you can reach this kind of tipping point match. And after that tipping point match is lit, it can really spread quite pervasively. And that makes everything a lot more difficult to implement from an organizational change and consultation perspective. Because everything I'm talking about will require energy and motivation. And certainly the level of exhaustion I'm hearing from my colleagues is quite real. I'm often asked about what I think is responsible for this low morale and exhaustion. And to me, it's a combination of this, of two ideas, this idea of obviously chronic stress and the idea that this stressor is the type that has the potential for many people to be traumatic. And so to start with the chronic stress component, when we talk about stress, I always think it's important to be nuanced about the source of stress. So hopefully we can feel a little bit more empowered about the type of stress that we can do something about versus the types of stresses that we very well may not have anything that we can do about in our circle of control. The stress model comes from the work of first responders. And it highlights really this idea of four buckets of stress that we experience. We experience traumatic injury, grief injury, moral injury, and fatigue injury, all these four types of stress. And I think what's unique about the pandemic is that many of us have faced all four types of stress at the same time, and in frankly a chronic way, not just a couple of weeks. And when you do that, all of it really leads to kind of the stress meter being on overload. I think you can also combine the fact that having stress is one thing, but the usual methods a lot of us use for stress reduction, bringing that stress meter down, were also limited due to the pandemic, such as seeing our friends or being with our family. And so that combination really has contributed to that overload and exhaustion we are seeing. In addition, I think the traumatic nature of the pandemic has bred a certain sense of disappointment, mistrust, or recalibrating of our beliefs about society itself. And the truth is we often see that in the aftermath of a trauma. This is a socio-ecological model of healthcare well-being. And the idea is there's all these numerous system levels that are responsible for whether healthcare workers could really do well coming out of the pandemic. I don't think I'm alone in thinking that really at every level the system has failed in some way. And so now I think there's two... There's multiple ways to think about this, but for me, I've always thought about two options. Either it became the case that everyone suddenly became incompetent at the same time, or for me, how I choose to use this model is that it helps me kind of see and remember that this really represents the nature of the virus itself, and how little we knew and understood about it, and how people had to make rapid decisions with limited, incomplete, and frankly poor data at times. At least for me, this helps give me grace and compassion to myself and to others, which I think at this phase of the disaster is really crucial, as I hear a lot from colleagues about rising incivility and kind of this fraying of social bonds and connections, including at work. And again, all of this is things that you want to know going into a consultation model, because you want to have the right expectations of how difficult change can be. I really do want to provide that background because, you know, this idea of aligning your missions with your organizations, assessing readiness for change, capacity of change, being self-aware of what you and your colleagues are already going through and what you'll have to give to these efforts is really critical, and I think will save you, hopefully, from a lot of heartache and disappointment as you decide what's possible to work on right now at your individual institutions. I'm going to spend the rest of my time really going through the four-part consultation model that you can begin, that you can use to begin the process of changing the climate from low morale to at least stabilization, and eventually really working on that culture change. The four components are engaging leadership, making sure you as one of the change agent leaders have appropriate frameworks in your head about how healthcare professional well-being works, using measurement to drive culture change, and then always remembering that this isn't a cerebral exercise. This is an exercise designed to actually act and scale the things that you do in the service of your colleagues. So the first step is engaging leadership, and when we think about engaging leadership, there's always this question of should we engage top down or bottom up, and like most questions in this arena of nature versus nurture, my view is both is always true and best, if possible. However, I also think it's often used as an excuse to do nothing if top leadership is not supported. So it's certainly and absolutely true that what you can tackle will be very different if top leadership is not involved, but in my experience, it's really been true that we can do nothing if the top leadership is not included and involved. In fact, I would say it's been equally hard but important to make sure that your colleagues and your team are on board with what you are thinking about and what you think they need. We have heard repeatedly that wellness interventions don't work when they're imposed on people and have not included them in deciding what could be helpful and how it could be helpful to them. This concept about nothing about me without me is really crucial for you to be thinking about as you create your change team. The rub is, of course, that when you ask folks if they're willing to be included in participating wellness initiatives, only about a third say they're very likely to do so. This is where I always highlight and emphasize this. This is about shared accountability. We have to do our other part, we have to do our part, and others have to certainly do their part and be engaged if we're to make a difference in the space. How do we increase the likelihood that people will be engaged? For me, the thing that's been most helpful is that we have to respect that all wellness is local. What people need, the existing culture, all have to really be respected if people are going to want to begin to look at joining your change initiative. What worked, how it worked, where I work, what worked, how it worked, where I work may have no relevance to how things work where you live and work. Plugging in interventions from other places is unlikely to make a meaningful change, in my view. You should certainly use those ideas, best practices, if you will, to influence your thinking, but you never want to take that shortcut of saying, hey, this worked at X place, let's just adopt it and implement it here. I don't find that to generally be terribly effective. Next, what can help get people engaged in moving together is really creating a shared vocabulary and one voice. Oftentimes, the shared vocabulary is around things like, what is wellness? What do we mean when we're talking about wellness? What are we trying to achieve? I've been on probably more wellness committees than I care to share with you all. The truth is, most have not been very impactful. I definitely know it was not because I wasn't a part of a team or a committee with talented and committed individuals. These are really caring people, smart people, but I always felt like it was because we never really created an agreement about what are we going to do? What's within our scope? What do we hope to achieve? You would start off with this idea of everyone kind of got together to be a part of the wellness committee, but soon, very soon, people will be kind of going in their own directions, making little tweaks about what they wanted to care about. At the end, we really weren't moving in one direction. For change to be executed, this idea of speaking with one voice, having a shared conceptualization is a very, very powerful tool in organizational change. I want to be clear, that doesn't mean we don't disagree and we don't debate. It just means that once we've kind of decided what we are going to do to move forward, we all have to make sure and be moving in that direction together. I also think, you know, making sure that that alignment that I talked about, that why, is really clear and that why is really a part of that shared vocabulary. What's your reason for caring about this and what's your system's reason for caring about this is important. One of the major errors I see here is that people often make an assumption about why someone would care or why a system would care. Really, there's four major cases that people have identified as catalysts for why organization systems begin to really invest and look and commit to this issue. Those four cases are the moral case, the business case, the tragic case, and the regulatory case. And so, what I find is many times, everyone assumes a business case is all the organization cares about. But my experience is that, you know, it certainly matters. Many organizations' journeys have started after a suicide or a tragedy. They've started after regulatory requirements. They've started after regulatory requirements. They've started after regulatory requirements, whether it be from the education bodies or joint commission, or even frankly, leaders just realizing it's the right thing to do as they watch the toll this work can often take on their workers. And so it's just really critical to figure out what are the right cases to make and how can we align around that shared language. After leadership, the second concept is this idea of having frameworks for what are the factors that matter in this work. And the framework that I wanna present today is from the National Academies of Science, Engineering, and Medicine, and they call it the Systems Model of Clinician Burnout and Professional Well-Being. At a high level, there's multiple system levels that impact on our work system factors, the demands of our job, the resources we have to do our jobs. All of that funnels through at the individual level. Each one of us feels that differently to create these outcomes of burnout or professional well-being that have outcomes and consequences at all levels, patients, clinicians, healthcare organizations, and our society. Next slide, please. And so, as you can see, a lot of times people start with the systems, but I actually find for consultative purposes, I like to start in the middle. What are those work system factors at our individual levels that we need to optimize the demands of our jobs and the resources of our jobs to help create a more fulfilling work environment? I think it's important to recognize some demands are inherent to the work that we do, while other demands are actually iatrogenic, if you will. They don't have to be the way it is right now. And for those demands, we are where we wanna focus our energy in to try to optimize those demands and minimize those demands or lessen those demands. And for those demands that are inherent, we wanna make sure that we provide sufficient resources to be able to handle those demands in a sustainable way. We also wanna be able to provide resources for each of us for our human needs. Why do we work? What do we want from our jobs? And to make sure to provide resources that people can develop in their careers and perform their work in the way that brings a meaning and is part of their calling. Next slide, please. It's important to remember that from a perspective of demands and resources, that how those demands and resources play out or how important they are to various different team members is really different. So while it is true that these circles all represent typical drivers or demands of burnout, which ones of these drivers really is quite different for physicians versus APNs versus non-clinical allied health folks versus nurses. And so appreciating not only your local culture and environment and system, but also each of those individuals within that system is really important so you don't make an error where you think kind of one size fits all in terms of your interventions or your consultation. Next slide, please. And then I like to go back to those systems, right? What are those different levels of the system? So that external system is the healthcare industry or government or laws or regulations or societal values about healthcare. That secondary healthcare organization, that middle circle is how, are the parts of our organizations, the leadership of our organizations, the governance, the rewards and benefits that our organizations have. And then that middle circle is really kind of that local team environment, the departments you work in, the inpatient unit, if you will, the technology, the physical environment, the conditions, what we do in that local environment. Recognizing that for each one of those drivers, those demands and resources, each one of these circles impacts our ability to address those demands. And so that concept is very critical for this issue of circle of control. Next slide, please. One of the hardest parts of this consultation is that a lot of times what I hear people do is say, hey, there's this demand at my job that I really, that's really problematic. I wanna try to work on that. But what they don't recognize is that as you think about whatever that demand is, which systems level is that demand under? So if, for instance, pre-authorization is the bane of many people's existence. The question is, is pre-authorization at the external system level, at the local level, at your organizational level, where are the problems with it? And once you recognize that, the truth is usually that there's lots of different systems that could be impacted to help that issue. But recognizing which ones of those are in your circle of control, which ones of those are within your influence, and you can say something about, but really it's not in your control to change, and which ones truly are outside of your control will help you preserve a lot of energy in the change consultation model. Next slide, please. And then finally, the systems, the demands, the resources, all funnel through each of our individual stories. We all bring our own personalities and temperaments, coping strategies, personal relationships, social support. I think this issue has been really brought to the forefront over the last year, year and a half. The needs of our minority physicians, they have different demands and resources potentially that are causing their fulfillment or burnout. Women physicians, women clinicians, clinicians with young children at home, caring for aging parents, each one of us has our own mediating factors that impact how everything else funnels through us and feels to us. And so recognizing that individual component is still very important. Next slide, please. In fact, I do like to spend a little bit of time on this idea of the individual and resilience and what all that means, because this idea of self-awareness, as you all know in this audience, is so critical. One of the things about our culture of healthcare has been we should always look like we know what we're doing. We should have the Stanford duck, is what this is called, right? We should be that duck that's floating effortlessly across the lake is what everyone sees. What people don't see is how rapidly the duck is having to paddle underneath the water to make it look like they're just floating effortlessly. That culture has caused some problems around seeking help when we need to, being aware of when our tanks are running not so full and we need to really take some time to rest and take some breaks for ourselves. And as you all know, self-awareness is the foundational building block of all other wellness initiatives. Next slide, please. I think it's also important to better understand resilience and what that means, because we hear a lot about it these days. I think at its most basic, people think about resilience as this idea of bend but don't break, right? So in this picture, the tree is clearly being impacted by some sort of wind and it's bending, but when the wind seizes it, it'll bounce back into its normal position. That has a lot of wonderful properties, right? One wonderful properties, obviously you're able to withstand challenges, but then bounce back. The other wonderful property is that it's pretty obvious to everyone, the tree is bending. There is some stress on the tree. It's obvious to both the tree and anyone looking at the tree. Next slide, please. But to me, my experience with healthcare workers is that we're not as resilient as we are resistant. Resistant is a little bit different property. Resistance is this property of being tough as nails. So the idea, right, is nails, you can just pound them over and over again. Nothing happens, nothing happens, nothing happens until it does, until it does bend. And the issue with that, of course, is that then it's very hard to straighten the nail out so that it can function again. This property is also very helpful, right? It's very helpful to have this property because you can go through a pandemic and we've all been through two years of being pounded and trying to provide service to our communities. But the downside of the property is oftentimes, because it doesn't bend at all, both to the person getting pounded and other people looking at this person, it's not immediately obvious that they've been through a lot or that they're struggling. And that can cause some of those problems around the Stanford Duck and exacerbate those problems of both self-awareness and peer awareness and other people knowing kind of what we're going through. I do hope one of the silver linings of the pandemic has been being able to talk about these issues more openly, discussing with people when we're struggling and then seeking help when we need to. And so this idea of the individual component is still important as we talk about organizational change. Next slide, please. I think it's also important to recognize that when we think about comprehensive wellness, there is resources that we need to send at every level. There are people that the nails have bent and those people we really need to provide high quality clinical treatment for. Whereas for many people that might be experiencing distress, providing peer support, informal support may be useful. And then I think everyone has benefited or can benefit from continued learning about self-care, resilience, stress concepts, and hopefully some of these organizational consultation models. I think we all know on this call that mental health services were not always perfect pre-pandemic, but it has been incredibly difficult now to get people into care that need it. And so making sure that we're kind of prioritizing and strategizing who are the people that really need clinical treatment versus some of the distress support systems that we have can be helpful to maximize our capacity to help treat our folks at this time. Next slide, please. So we've talked about leadership. We've talked about frameworks that you can use as you start thinking about what demands, what resources need to be worked on. And then we can always use measurement to catalyze change. Next slide, please. One of the biggest issues around using measurement tools around fulfillment and burnout, et cetera, is that we can sometimes make the mistake of forgetting what is a leading indicator that we are making a difference versus what are lagging indicators. If you would hit the next slide. And so the important thing here is the frameworks have taught us that burnout, fulfillment have all these drivers, all these resources, it's complex. Hopefully what that slide reminds you is that there's no silver bullet initiative. There's one thing you can do that's going to change burnout for your organization or your system. That's critically important to remember because in that case, burnout is a lagging indicator. Burnout isn't gonna change for a while. That doesn't mean you're not doing really important stuff. You're on your journey, you're on the path to creating that culture of wellbeing. And what the leading indicators are are really those drivers, right? If you do an initiative where you're trying to address this driver of professional isolation, feeling really isolated, if your intervention helps improve isolation, you've done something. It may not fix burnout because burnout is lagging, but you are seeing that you are making one of those drivers better. And once you start making more of those drivers better in a systematic way, that's when you'll see some of those lagging indicators change. I think the other important concept besides leading and lagging is what are organizational metrics that everyone's responsible for versus what you as a wellbeing consultant are responsible for. So things like burnout, turnover, recruitment, retention, satisfaction, they have so many variables that everyone has to own for it to matter that if those don't change, that doesn't really reflect on you as a consultant team. Whereas what you are responsible for is what you're working on. Are you helping make the drivers better? Is what you created being utilized by the people, right? Again, it's fine to create things, but if no one uses it, it doesn't really matter. And after they use it, do they like the interventions you've created? Are they useful? Are they helpful? And so trying to separate those things out can be very helpful in setting expectations with your system about what you're going to do and what changes they might be able to expect to see. Next slide, please. A part of measurement though is to be very careful right now, given the climate, is that there's a lot of survey fatigue. Nobody wants to fill out a 30, 40-minute survey if you would click it next. But I do want to remind people that for me, what I have found working in this work is it's not survey fatigue that is the problem, it's the lack of action fatigue that people feel. That's what makes them cynical, is that, hey, I'm fine answering things if I can trust that you're gonna do something about it rather than ask it, never even share the results, don't really have a plan on how to address some of the things you asked about. And so being mindful of, if this is lack of action fatigue, asking a terribly long survey may not make a lot of sense. It may make much more sense to pick a short survey that you have some ideas about what you can do about after you get the results. Next slide, please. There's a wonderful website in the National Academy of Medicine that provides numerous instruments to measure some of these drivers, burnout, well-being, that I did want to share with you all as well as a good beginning place to identify some of these instruments. Next slide, please. And then finally, always acting and scaling, right? We have a tendency sometimes to have this be a cerebral exercise rather than an action-oriented exercise, which is what leads to that lack of action fatigue and cynicism, truthfully. Next slide, please. What I always say is, we can sometimes make this really complicated, but at the end of the day, if what you can do in this consultation model is to remove the pebbles in people's shoes, what are those little annoyances that you go to work and you're like, I don't understand why this can't be fixed. This seems like such a little deal, but it just grates on me. Those are the things that you want to focus in on as you start your journey. Having those small wins, building that momentum, overcoming that sense of exhaustion and helplessness that people have right now is really, really gives you the momentum and energy you're gonna need to make broader, larger changes. Next slide, please. And the way we kind of think about those pebbles is this kind of two-by-two box of what's feasible. As you begin to think about what are the drivers, what are the things that I can do to help those drivers, what's feasibility look like and what's impact look like? That bottom right, small, quick wins are those pebbles in the shoe that we talked about. A lot of times people get stuck on high impact, low feasibility, the upper left corner. And that's when people get tired and they feel like they get stuck and they give up. But you can't address that yet. You have to build that trust, that momentum to be able to address that. Where you wanna get to is those small, quick wins and that upper right corner of high impact, low feasibility whenever those opportunities arise. Next slide, please. I recognize that small, quick wins oftentimes, initially people go, you know, that's not a big deal. Like that's, you know, it's a much bigger problem. But, you know, I think there's a saying that people overestimate what they can do in one year and underestimate what they can do in five. And truthfully, that's been our experience. We started with one little program, our flagship program called the Scholars of Wellness a year before the pandemic. And that one program generated those wins, increased our circle of trust and influence to create our overall physician wellbeing program. So I believe in it, I've seen it work. And I think it helps create a sustainable journey for everyone. Next slide, please. And that journey concept is really important, right? A lot of these talks, people that come in and speak about this issue, you know, people go, what does that do really? And it's true. Many of these initial talks or speakers are going to help raise awareness. The bottom left of this slide is really as you go through your journey, these, the talks, et cetera, the awareness raising don't seem to have a major impact. That's correct. But they're a part of the journey. And what I've found is that you can't skip steps. You can accelerate, but you can't skip steps. You raise that awareness, you understand those drivers, those demands, those resources we've talked about. You start conceptualizing wellness as an operational problem. And that's when you start seeing really transformative change at an organizational level where people really say, okay, you are fixing what has made, what was burnoutogenic, if you will, in the first place. You're appreciating that the system had to get fixed rather than just asking me to be more and more resilient. Next slide, please. And just want to close with that journey. Let Northwestern being recognized as a joint medicine organization in 2021 by the AMA. And that really demonstrates this idea of the sustainable commitment over time to creating that environment. It does not mean we have figured it out, but it does mean that we're on that journey and that we have a path forward to be able to make, to be responsive to our colleagues. Next slide. I want to thank you all very much. And again, apologies for the technical difficulties in the middle. No problem. Thank you so much for such an insightful and timely presentation, Dr. Agarwal. Before we shift into Q&A with you, I want to take a moment and let our audience know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. Individuals can download our app now at smiadvisor.org forward slash app. But we would really love to hear some questions from the group. I was, you know, what you talked about was, resonated so much with me and I'm sure with our audience. I wanted to talk for a second or get your feel for a second about something you said very early in your talk, which was the contagious nature of low morale and emotion. And I'm wondering how we stop that contagion or address that contagion. If you had any thoughts on that. Yeah, I think that's a really good point and something I spend a lot of my time thinking about right now. Because as I said, if the match gets lit, everything becomes much, much harder to do. I think there's been a couple of things that we've tried to do is... If you think about the vaccinated population in terms of the infectious world, the idea is that if you have enough vaccinated people, there's herd immunity that won't let the virus spread. So I think about that concept in this area as well, is that we have folks who, by whatever the reason, still have not... Don't have the contagion, A. B, we've developed wellness leaders over the last three or four years, as I showed you, that are kind of embedded in all these different departments. And what we try to do is we're leveraging those people to be sort of the vaccinated people in between that can kind of do a little bit of a break from spreading that contagion, kind of like wildfire. And I think the second thing you can do is really be very intentional about this concept and say, hey, we really have to kind of do something right now. This is our chance before the match gets lit to do things that are gonna be much easier on the preventative end than on the rehabilitation end, on the back end. And so the things we really talk about is really getting leadership engagement, good transparent communication, really working on the civility concept that I talked about. We're seeing a lot of incivility and reminding people that, look, there's a lot of things not in our control right now, but how we treat each other, how we talk to each other, how we respect each other, that still is in our control. But if we lose that civility with each other and we let kind of the fraying of our community happen, then this stuff becomes very, very difficult to address. I like your term of incivility. Actually, at APA, just in the last two weeks, we were asked by the HR department to watch a really good YouTube... I'm sorry, not YouTube, LinkedIn video on civility, microaggressions, et cetera. And it was really just a great reminder of all the little places where we can provide more grace and compassion, as you said. And even myself, as I listened to it, I could feel the slip of incivility at times, and it was a good check in with myself, so I thought that was great. One of the individuals who's listening asked, did the scholars of wellness place any time specific goal of expected change? For example, cultural change in six to eight years, et cetera? That's a great question. I wouldn't say we viewed it like that. I think in my own head, I had goals for it. There was two separate goals, and we can talk about the program more, but the idea was to train leaders in each department that could be constructive change agents, very similar to what we tried to accomplish in an hour today, so that, again, our core tenant is all wellness is local. And so me, as a psychiatrist sitting at the top of an 11 hospital organization, can't tell the radiologist what needs to happen. We have to have people at the local level that are empowered to be constructive partners. So each one of them becomes a part of our team. And over time, we had the sense if we could reach that critical mass, going back to that vaccination analogy, if we could have enough people that were invested in this, committed in this, shared our vocabulary and our approach, that would make a difference in two to three years, at least in my head. The second part of it was each one of them did a project to apply the knowledge and skills that we taught them over the course of a year to make a difference at that local level, to remove some pebble in their shoe, to help build that momentum in their local departments and divisions. And so for each of those projects, the expectation is we would see some momentum at the end of the year, frankly. So there was the broader issue that we anticipated you would need a certain amount of scholars to have, quote unquote, herd immunity, but there was also that immediate small winds, pebbles sense of the ability that we can make a difference on an organizational system driver of burnout, that we felt like could happen much more quickly. So remember your slide with the four circles, which I actually took a screenshot of because I loved, where you had the different disciplines and you had the circle and you made some parts shaded and some others and talked about drivers. Someone wrote in and said, talk a little bit more about what you mean by drivers. Yep, that's great. And I used some terms interchangeably that made that confusing, so I apologize for that. When we talk about drivers, I'm talking about that slide from the frameworks around demands and resources. And so demands and resources are our drivers of whether they be fulfillment or burnout. So if we can add meaning to work, add autonomy to work, add flexibility and control to the way we work, those are positive drivers that can lead to fulfillment. On the other hand, if our, for instance, EMR is horrific, our teamwork processes on how we have our patient flows go through, our intakes, etc., are not efficient. Those are demands that can drive us towards burnout. So the demands and resources are the drivers, optimizing them leads to the outcomes of either burnout or fulfillment. So someone just wrote in and said, and I think we're all wondering this, what is a good starting point for professionals entering the well being consultancy space? Well, I guess I was thinking of it differently. I was thinking of, can someone help and be a consultant to me to make me feel better? But she's asking, professionally, how does she... What's a good starting point for professionals entering the well being consultancy space? Yeah, I mean, I think I have found... So obviously, they don't teach us this in med school. This is mostly been learning after my residency. And what I have found has helped my career has been executing on exactly what I've presented today and building trust and showing people that we can have this be different by picking one or two things that we worked on. And people said, oh, wow, that actually worked. And then that led to bigger pebbles that we could take on, if you will. Then we were able to take on some stones and some rocks, and then we were able to build more trust, more buy in, more momentum to begin to have at least some influence on the bigger mountain challenges that also exist that are, frankly, outside of any individual circle of control. And so I just think it's... Why I started the way I did was I really don't wanna be Pollyanna shit on it. This stuff is hard. This time is hard. And so really identifying this idea that there's a ton of cynicism out there, we're starting from a place of low morale, that makes this work a lot harder. But your ability to build trust and surprise people, frankly, is cool too, because if you can start addressing some of those pebbles, that right now there's a lot of sense of nothing can make it better, everything's terrible. You can really flip the script a lot, which will buy you as a consultant a lot of credibility, a lot of trust that can accelerate your career. Terrific. Any thoughts... This is someone who just wrote in. Any thoughts on the ongoing stigma within the helping professions that seeks to ostracize providers who seek mental health treatment? Yeah. To me, it lends itself to the frameworks that we just talked about. Right? There's an external problem, right? Is if the credentialing bodies at a national, local, state level continue to make it punitive to have sought help, then this becomes a real challenge. There's problems, right? So there's the national credentialing boards, and there's the credentialing that each hospital has, so that's the organizational problem that's around stigma, and certainly that culture problem is if someone discloses a need or seeks help, if people look at that negatively or negatively impacts career development or career advancement, then that organizational culture will perpetuate stigma. And then certainly at an individual level, a lot of us have been trained in this culture that it's hard. We're sort of selected to, quote unquote, be tough. And so some of that internal guilt, internal self awareness issues that we talked about, we have to work on as well. And so all of us have a role to play in making this... In reducing the stigma and allowing people to recognize that seeking help is a sign of strength, not a sign of weakness. Those things all have to happen at multiple system levels, in my view. I noticed on your slide where you talked about how you've built over the years this program, and I noticed that there were several in this year that said P2P. So I'm wondering if you can talk a little bit about that. I'm assuming that's some sort of either physician to physician or peer to peer, and tell us a little bit about how that works. Yeah, so if you remember that triangle I talked about, right? The top of the triangle was people that really need clinical care, and so that's impairment disease. Then the middle of the triangle... The bottom of the triangle is like resilience, prevention, self care stuff. The middle of that triangle is around distress. And distress, in many cases, for many issues, is a non modifiable demand, right? We work with patients that may die by suicide. That's an inherent demand and risk in our field that you can't design around totally. And so if someone experiences an adverse event like that, that's an occupational hazard of treating serious mental illness. And so we need to make sure that, just like a construction worker is given a hard hat because they can't design around the fact that something might fall on their head in a construction site, we have to provide occupational resources around this demand that most of us are likely to experience at some point in our lives. And so one of the core infrastructure, well being infrastructure initiatives at most programs that are kind of leading this well being culture movement is called peer support. And you were exactly right, P2P is our physician peer to peer support network. And initially, we launched right before the pandemic, it was around, just like the example I gave you, an adverse medical event, a medical error. And that's generally where a lot of people start. What we found through the pandemic was we were providing a lot of support around compassion fatigue, COVID distress, etc. And we're like, wow, this doesn't just have to be about adverse medical events. This is really not a program, it's really a platform of support that we can use to provide people support and help them with their distress around various issues. And so we started building these bolt on programs. So for instance, one of them was around providing support if a physician was undergoing litigation. Obviously, one of the most difficult times in any physician's career, and the literature is pretty clear about the negative ramifications on wellness and mental well being. The program we're working on right now is to provide support to physicians who have experienced harmful bias or discrimination at the bedside by patients. And so there was a lot of stuff written last year, especially it's been written well before last year, but there was a lot of things pointed out last year about the impact our underrepresented in medicine physicians experience the bias and discrimination and the impact that can have on their experience of being a physician. And so we wanted to be able to provide support around that. And so there's other things like that, where there's these common stressors that people experience, and we wanna be able to provide some support to minimize the distress and have people know that they're not alone. So I'm thinking back to my experiences over my career, and there have been places that I've been at that have had the fortunate situation where there's been someone like you. For example, at UCLA, when I was there, there was a person who was really assigned to faculty wellness, and there was a very... You knew that that person kept things confidential, you could go to them any time, it was an open door policy. There were groups and things that you could go to, but you could also just go to this person. And I'm wondering how sites, whether they're clinics, small community clinics, or whether they're in hospital systems, how do we begin to talk to our administration to develop a program like this? I mean, I myself can think of what the value is to me, but how do we sell it to administrators? And also, what are we trying to sell them? Do they need one person to start this program? Do they need a whole department? How do you get this going at your place? Yeah, in a sense, that was the meta point of the whole talk, right, is how do you get to be identified as that person, right? And to your question also, well, if you don't wanna be that person, then how do you advocate to your leadership that they need to come find somebody that does have it? So I think those are two different questions. The first one is the path that I've shared here, is really, I think, again, this is a time where, at least in my experience, people want help with this, leadership wants help with this. They know it's a problem, and so there is an opportunity right now to say, hey, you know what, I'd like to take on a little bit of this work. This work doesn't happen... It's very hard for this work to happen in the margins of your busy life, and so you have to ask for some protected time to be able to do this, but I do think one person can be a start, and is one person... We started with one person for 11 hospitals, and so it felt overwhelming too, but again, that's where those expectations that hopefully we talked about today of slowly but surely, just continue to build your trust, keep fixing pebbles, keep developing people, and more and more resources can flow your way over time, I think is important, but I do think this is a time where people... If you don't wanna be the person, then I do think firing off an email suggesting this very idea of, hey, we need to either... Generally, what I see organizations do is they first either measure something and the measurement tells them, man, we got a real problem, and that generates interest, or two, just people shooting emails off to people and say, look, this is a real problem. We're really struggling, and they hear it from numerous people, it lends to something usually happening or somebody being given some time to be able to start working on this in a really organized way, because the ad hoc way is what I did for many years before this happened. It was okay, but it's really hard to make a lot of change. Right, and I... This could be a sort of silver lining of the pandemic. We needed this before the pandemic, but because there's so much pressure on recruitment and retention of faculty right now and staff, this is our moment to actually get this in place. So I think you're right that now's the time to raise the flag, and I think they're more open, administrators are more open to set aside time and to invest some money, because they see that an investment in one or two people really can help retain a wide group of our workforce. So I do appreciate that. And just remember, retain could be the right outcome, right? Retain is a business case. Right. But I also do feel like people feel it themselves, right? So maybe before they were like, I don't know what the people are whining about. Everyone feels it right now. And so the more case is actually a lot stronger right now for a lot of people where they've heard it. You won't be the first person to tell them, man, I'm at my wit's end, and I don't know how much longer I can do this. They've heard it. And so I wouldn't discount the moral case as well right now. Yeah, yeah. No, and on my point, I've been recruiting for positions, and people are looking for a more whole experience that's not just the tech of the job and the scope of the work, but what is the culture? I mean, people are more savvy about it now, because they're probably leaving someplace that didn't take care of them very well. And they wanna know, what do you have that's part of that? And I think that's a fair question, fair question. 100%. Alright. Alright. Well, thank you so much for sticking with me and answering our questions. There have been a lot in the chat box about what an excellent talk this was, and again, so insightful and timely. If anybody in the audience has any follow up questions about this topic or any other topic related to evidence based care for serious mental illness, we have clinical experts available for online consultation. Any mental health clinician or peer specialist can submit a question and receive a response from one of our SMI experts within 24 working hours. Consultations are all free and confidential. Now, SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence based care. We'd encourage you to explore resources available on the mental health, addiction, and prevention TTCs, as well as the National Center of Excellence for Eating Disorders, and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes following the closing of this webinar. You'll then be able to select Next to advance and complete the program evaluation, and then claim your credit. Please join us next week on December 9th, 2021, as Dr. Niranjan Karnak with Rush University presents Mobile Technology for the Treatment and Support of Homeless People Living with Serious Mental Illness. Again, this free webinar is next week, December 9th, 2021, at 3pm Eastern Time. Thank you all for joining us today. And thank you again, Dr. Agarwal. Until next time, take care.

webinar

culture of well-being

evidence-based care

organizational goals

consultation model

resilience

peer support

mental health treatment

workplace stress

systemic level