Thank you, Dr. Klein. That was excellent. It's going to be quite the challenge to follow that excellent presentation. And there's a fair amount of overlap, which is good. And this is a this is a topic that requires some reinforcement, I think. So that's that's great. All right. So I was assigned the topic of, um, what are the benefits of sharing your thoughts and feelings and emotions? Um, and so I think, uh, this is an important topic, of course. And like I said, there's a bit of overlap with Dr. Klein's talk that he just presented. My disclosure side's a little different. Um, I was assigned this topic of the benefit of sharing my thoughts and emotions with others. And when I received the assignment, I shared it with the mother of my 3 children who spontaneously burst out into the most raucous laughter that I've heard quite sometimes. She was incredulous, in fact, and she shared immediately that you are the last person that should be speaking about this. And to be honest and full disclosure, that brought about some emotions that I'll try to share with you later. But, um, but this is where I've been assigned. So here we go. Thank you for the introduction about Dr. Wu's important work coming out of Johns Hopkins. And I included a separate anecdote that was from his original article that I want to share with you as a prelude to what I'm going to talk about. Um, and again, like you said, this is a quarter century ago. Um, and that's important to note. He began by recalling experience from his days in training. So, um, I'm going to read this. So, um, I'm going to read this. became the second victim of error. Now, a quarter of a century later, the point here is fairly obvious, as was illustrated by Dr. Klein. Although the patient suffers the most, there are others who suffer, including the patient's family members, as well as members of the health care team. Certainly, a lot has been published about the effects of procedural complications on operators and health care team members over the past 35 years. So, again, although my assigned topic is focused on the benefits, we also routinely counsel the patients on the risks of therapy. And just to reinforce, it's important to understand the perceived risks that act as barriers to seeking support or sharing what we are feeling or experiencing as operators that are part of a procedural complication. There was a 56-question survey with a focus on physician distress, including after serious adverse events. That was developed at Brigham and Women's and administered to 108 procedural physicians across a few different specialties. And these barriers can lead to operators feeling frozen, unable to let it go. That's another movie reference for you, Dr. Klein, when it comes to sharing their emotions, right? So, some feel that they're so burdened with their care, with the demands of their care, they don't have any time to process from one case to the other or to heal. There's a lack of confidentiality, and there is a concern that this is going to have a negative impact on the career, and you've already expanded on the stigma. So, there's a lot of barriers, and these would be interpreted as risks to prevent somebody from sharing what they're feeling. And it's well established now that in the absence of mechanisms for healing, physicians can find harmful ways to cope with anger, outbursts in the cath lab or the next day in clinic, rejection of blame, right? In my 11-year career, one of the most alarming encounters I've had with another interventionalist was when they flatly told me that when a patient suffers a complication, they don't feel bad, they don't feel responsible. And I was alarmed by that. But what I observed from them in reality was something very different, right? They had defensive postures, anger, throwing the entire team under the bus, throwing the trainees under the bus. That doesn't look like somebody who doesn't care. And so, a modicum of compassion goes a long way. But what is it about, you know, us that prevents us from sharing our true emotions? So, we have to think about all of these things. It may have been the case that past experiences had led to a chilling effect on one's ability to navigate the trauma of a complication. And so, we have to have a network that is supportive enough and a safe place for us to heal. On another note, I sit on the VA's National Major Adverse Event Committee, along with Dr. Atkinson, who's one of our panelists, and is chaired by Dr. Zimit out of San Francisco. So, whenever there's a major complication at a VA cath lab across the entire VA network, which is, you know, one of the largest healthcare systems in the United States. So, this includes perforations, strokes, fatalities. There are some automatic reviews and some that are ad hoc. Two of us on this committee review the films and the medical record, and at least one of us reaches out and speaks to the operator. And in my eight years of serving on this really important committee, I've learned a lot about how operators deal with these complications emotionally, right? So, it's part of the peer reviewer quality process, and so many of us are deathly afraid. We're frozen. We're defensive. I've seen people paralyzed by fear of retaliation, and I've seen blatantly fraudulent documentation. And so, what drives us to these behaviors? The VA system for cath lab complication peer review is actually a wonderful tool for an operator to speak with external experienced operators as part of their debrief and processing of the complication. They typically express deep gratitude for just listening to their perspective, and the process is not designed to be punitive. It's centered around collaboration and with a focus on quality improvement. I think it's clear that learning to cope with complications at an individual level with support throughout your institution is really for everyone's benefit, especially to optimize transparency during the peer review process. It's important because often these processes are really the voice that the patient or the first victim has, right, after the fact. So, it's quite important that we focus on that. So, what do we stand to gain by sharing our thoughts and emotions, right? I want to share another anecdote. Dr. Lombardi's complications course is annually one of the best courses in the country, and I attended for the first time this past August, and it was an exceptional course, but I want to share an anecdote from it. One that was so touching, I actually had a hard time hearing about it, right? So, in one of these sessions, and I'm not going to name who, but a very experienced senior operator talked about how he dealt with the emotional burden of a recent, very difficult complication, how it affected himself and the family. And it was a beautiful anecdote, but then he shared something very much unexpected to the audience. He shared a picture of his father. He then shared with us a very heavy moment that his father had passed away that very morning of the presentation, and there were audible gasps throughout the entire conference room. It was really something that was a shock to a lot of us, and there were a lot of tears that were shed. I, myself, lost my father six years ago, and I was so overwhelmed with emotion that I decided to step out of the conference room and let the tears fall, because I knew it would be a distraction to the audience. So, in retrospect, what was accomplished by this speaker sharing his grief and vulnerability with an entire audience of experienced interventionalists and trainees alike? What was accomplished with that? Really, it was a master class on how to gain empathy. Every single person in that room instantly felt for the speaker and their loss and was moved by them. And I imagine that his action showed all of us what bravery and courage look like in the face of trauma and loss and grief. And we're all better off for it because of what he did. So, as an operator who is part of a serious complication, what do we stand to gain by sharing our thoughts and feelings? Remember, we are part of the healthcare team. We're not the entire team. We're part of it, and it's crucial to process these emotions as a team. So, when we share what we're feeling and what we're thinking, first and foremost, we're supported, and we support each other. People see us as humans and not just emotionless technicians or robots, right? We have feelings. We're human beings. We're grieving and suffering, too. Our teammates then feel safe to open up to us, to communicate, and that way we can process this together. And it's really important that I, you know, as a cath lab director, for example, we have these debriefs. Some of the most impactful and meaningful conversations I've had after a complication are with my entire team. Because what happens? I'm able to connect with my team members in a way that strengthens the relationships I have with the people that I depend on to do my work, right? And it makes them feel empowered and unlocks different levels of empathy that wouldn't have otherwise happened. And I think that's the cornerstone, the main benefit of sharing our thoughts and emotions, right, is gaining that empathy. And I think that that is not only important in your healthcare system for your team members and your colleagues who are doing peer review, your patients, et cetera. So, you know, we talk about helping me helping you, right? It's not only a great line from Jerry McGuire, but it's true. We need to dwell on how we can effectively role model how to deal with the psychological aftermath of a serious complication for our colleagues, our staff, and our trainees. And again, this is why a debrief is a really important role, an integral part of the Cath Lab after a complication, and especially something as traumatic as a Cath Lab death. As an attending and primary operator, everyone thinks of you as the captain of the team, and everyone's affected by whatever just happened, right? And again, so showcasing your compassion and your vulnerability, your genuine concern, not only for the patient, but for the whole team, unlocks that empathy across the board. And so I think that's an important step to take. And at the end of the day, after I've had this conversation debrief with my colleagues, I know that I'm going home that day. I'm not alone, right? I still feel terrible about what might have happened. But that helps with, you know, with healing, and it helps with understanding that, you know what, I wasn't alone that day. I had an old team, and we're there rallying around each other. And I'm in a better situation to handle this long-term aftermath that will invariably affect us, right? And so, you know, after a complication, how do you deal with your emotions with respect to sharing that with family? So another anecdote I'll share. Early in my career, this is after two years of me being in private practice, my first year as an academic attending in my current group, I was referred an inpatient with chest pain in a normal troponin and normal EKG by a senior colleague. And this patient happened to have a calcified mid-LED stenosis. So I said, okay, you know, I think it's reasonable to treat this mid-LED. Angioplasty didn't appropriately reduce the stenosis. I didn't want to perform a real arthrectomy after the angioplasty with high-pressure non-compliant balloon. So we didn't have IVL at this, you know, stage in my career. And I ended up deciding to abort the procedure, admitting the patient, putting him on heparin, and then having him come back for stage arthrectomy. There was normal flow, but the patient continued to have chest pain despite normal telemetry and normal coronary flow. And that should have alerted me to other possibilities, right, other conditions that maybe I should get a CTA. Maybe this patient's having something else happen. I trusted and accepted the judgment of my senior colleague, which wasn't wrong. And ultimately, a couple hours later, you know, after I checked on the patient, went home, I got a call from my first year fellow. Hey, the patient's coding. I rushed back and, you know, we couldn't save this patient. He ended up passing away. I suspected the patient had something like maybe an acute or an aortic dissection and requested to meet with the family both that evening. There was a limited amount of family available. So both at the time of the complication as well as the next day. So a large group of family members come the next day. Initially, I'm calm and collected while describing the event and offering support to them as well as support of an autopsy. I clearly was grieving along with them, right? They see that too. I see that they're, you know, grieving from their loss and that provokes a profound emotional response in me. And they see that. And they ultimately understood that I genuinely tried to do the best I could for their family member. And, you know, they declined my offer of an autopsy. I kind of wish I had wished at the time in retrospect that they accepted it because, you know, I was unclear about what happened. But what's important for them was that they needed to know the person who did the procedure did it with the best of intentions and genuinely cared about their loved one. And was affected by what happened. And that's what they took away from their debrief. And that's what helped them move on. And that's what helped them bring closure. So it's not just about ourselves and how we heal. We have to be mindful of all the different lives are affected. In my preparation for this talk, I came across a wonderfully constructed and thoughtful review, which is down here, which I'll leave at the end. And it's a thoughtful review of the psychological aspects of procedural complications, including from the perspective of pediatric surgeons. If you can imagine the trauma of having a catastrophic or fatal complication in a pediatric patient. And I'd recommend anybody who's interested in learning more about this subject to kind of spend some time reading this overview. But I wanted to share a few highlights from what I've learned. It reviews the biological and short and long term psychological responses that occur. A lot of which Dr. Klein already went over. And as well as the factors that impact the severity of the response. And one of those is the level of experience of the operator. Importantly, only a third of operators reported that their ability to cope with complications improved as they advanced in their careers with more operating experience. And another really important point I want to spend some time stressing is that early career operators, women, minorities and trainees are really often marginalized in our health care systems. Especially when it comes to coping with complications and trauma from adverse events. And so that can lead them to being really vulnerable in terms of having impaired emotional recovery. So just as Dr. Klein shared that example, I want to tell you that my initial reaction to that 35-year-old female interventionalist who's running into trouble is, does she have the support she needs? Does she have the help that she needs? That's what we should be thinking of. And it's really important to be sensitive to this as colleagues or leaders in our centers. This article, they proposed a coping model by which individual operators and institutions can work to improve the well-being of operators and manage the reactions to stress of a complication by these six factors. And so, again, we all improve with understanding experience, trying to be unbiased with what happened, understanding that there are ethics that guide what the transparency should be. But then from an institutional standpoint, you got to have that supportive network. The first and last time I had a perforation, and this is about maybe five years ago, Dr. Trong and Dr. Obadiah, both of which were on this call, they showed up to help out. And I felt very much supported, and the peer review process was one that was not punitive but helpful. And so I'm so fortunate to be in an institution that has supportive partners that really care about me, and they know I care about them. And that's what we need to do. We need to raise awareness and amplify the sensitivity to marginalized groups and remove these barriers. Secondly, we have to understand that the first and second victims are always linked, right? So we have to care about the patient and their family, and we have to understand how to be successful in improving their outcomes. And if the patient's passed away, how do we support their family? And that ultimately has been proven to help the second victim deal with the complication as well. And then as a society, we have to prioritize emotional and spiritual well-being over just the physical aspects of the complication itself. So with that, I'll end, and I really appreciate the opportunity to seg from Dr. Klein's talk to this. Thank you.

emotional well-being

medical professionals

support networks

transparency

healthcare culture