Good evening, everyone. I'm Drew Klein, one of the interventional cardiologists here at Piedmont Atlanta, and thank you very much for joining us and to everyone for joining us for the second webinar in the wellness series. I want to start off today by, first of all, thanking everyone who's going to be speaking today, specifically Dr. Asar and Lombardi, as well as an esteemed panel, Dr. Dupont, Dr. Chong, Dr. Atkinson, and Dr. Abudaya. I also want to thank the SCI staff for supporting us and bringing this all together. As you may know, getting interventional cardiologists together is somewhat like herding cats, and sometimes it can be challenging. So thank you to the SCI staff and for everyone for making this a priority and for tuning in tonight. This is the second of our series on the wellness or well-being, where we really try to address the emotional aspect of the EQ aspect, if you will, of this profession, and hopefully provide some tools by which we can better cope with the immense mental challenges that each of us face every single day in this profession. Complications are inevitable, and they will happen to every single one of us, and they can be devastating to our careers and to our psyche. And we, as the SCI Wellness Task Force, really have opted to address these with this webinar. I think Andreas Grunzig himself said, if you're going to do this, you should expect complications. And these complications, again, can affect every single one of us in various different ways, depending upon our background. They can be minor. They can be exceptionally morbid, sometimes leading to permanent disability and or death. Each of these have our own impact. Each of these events impacts us in an emotional, physical, spiritual, and basically a diverse way that every single one of us as operators and our teams get impacted. And so with this, I want to go back in time to when each of us were residents and probably to this day, if you're in morbidity and mortality conferences, and kind of bring us back to that. And a story that came up as I was preparing this talk, which is as we would prepare as residents for these talks, M&Ms, we would nervously put our cases together and hope to God that we didn't get called on too much or didn't get crucified too much by our house, by our attendings. But we probably all feared what this would bring up. What would our reputations be with the attendings? What would our reputations with the medical students or the fellows? Or worse, our own colleagues be after admitting and going through this mistake. One time in M&M, after I was called on to comment on one of my colleagues' actions, they panned to a senior attending. And this case happened to be someone who was performing a diagnostic paracentesis in a patient with advanced ovarian cancer and at that time happened to hit bowel with the needle. And they panned over after they asked for my response, which I don't even remember what it was, but they went to this world famous hepatologist and said, Tony, what do you think about this? Expecting him to jump on board and start crucifying this attending or this poor resident about what had happened. And to his honor and to his style and more importantly, his immense ability to make everyone laugh, but also show such grace, he said, well, the first time this happened to me. Of which everyone started laughing, implying that, in fact, it happened. He thought to himself, this is exactly what you have in the in the needle and something about a South African accent about saying that made it sound so much better that this complication had occurred to him not just once, but several times. And I think at the end of the day, what that tells me is that each of us have a choice. We can have a choice when complications happen to show some grace to ourselves and to our colleagues, because at the end of the day, we as humans, not just as physicians, have a tendency to be hypercritical. Shakespeare once said the evil that men do lives on after them, while the good that they do often is interred within their bones. So it is not just a hypercritical interventional cardiologist kind of type A personality that is hypercritical, but we as humans. And I think that hepatologist statement and the way he handled that sort of morbid kind of nerve wracking environment was to bring some humor to it, but also show some grace. And I think each of this, as we approach these emotional burden of complications, can actually do that. And so with that, let us begin and let's talk about the stigmas attached to the emotional burdens of complications. What I would like to first do would be to break down what these emotional burdens might be, but also what stigmas might be, and hopefully kind of intricately link them together with an idea of basically addressing this from top to bottom. And so, first of all, my disclosure is I'm fully committed, like Bill Lombardi is who joined us today, and I think all of us are, to changing our culture of medicine. I think all of us are hypercritical. All of us are harder on ourselves. And I think all of us, of course, would love to live in a world without complications. And I always tell people I'm not going to do this because once that happened to me, and good judgment comes from experience and experience comes from bad judgment. But I think at the end of the day, we will continue to have complications. The best of the best will have complications. It doesn't matter. It will happen. Not when, not if, it will be when. And I've had my share of complications. I'm mid-career now. I've been doing this for around 15 years. And trust me, I've seen plenty of patients come in the lab, unfortunately walkie-talkie, and not leave the lab. And that is devastating. And I can tell you every single one of them on one hand. And I think the idea is that I'm not perfect at this either, but my disclosure is that it is an ever-evolving process in how to deal with complications. And I think all of us have to understand what is the evolving process for each of us individually. Well, here's a perspective. I found this on the internet, which I thought was interesting. It's an Athenian physician from 2 AD, that the eternal duties of a physician are first to heal his mind and to give him, and that first and foremost, give assistance to himself before giving it to anyone else. Sort of reminds me of when you're on a plane and say, if the air oxygen drops, then you should take care of yourself first and then somebody else. But I think this underscores the importance of taking care of ourselves first, or else we can't take care of other people. When it comes to complications, medical errors are currently recognized as maybe a third leading cause of death, almost 440,000 annual fatalities, secondary medical errors, given around 600,000 physicians. That's one death due to a medical error for each doctor nearly every year. So each of us directly or indirectly will be involved in this no matter what we do. And so with that, we must understand how to handle that. As a background, for those of you who are interested in this topic, we talk about little T trauma, big T trauma when it comes to complications or to events in life. I would say that complications are big T trauma or big events that happen. These are events that can limit a career, end a career. And I think it's really important to underscore that these are just as important as some of the other trauma, big T trauma that occurs and to take it just as seriously. So let's start off by looking at what stigmas are. Well, what are they? They are a mark of disgrace, according to Webster Dictionary, associated with a particular circumstance. And I think it's really important to understand that when you look at shame or disgrace or dishonor or stain, that this is an understanding of not only how stigmas are from within, but also externally. And often we're the one feeling pointed at, just like that M&M. And I think it's to understand that the power of stigmas is beyond what I can mark with words. And feeling that from a day-to-day perspective, it's an understanding of where stigmas are. And I think most of us really understand about where we are from a social or public stigma. We think about stereotypes, prejudice, discrimination. But really, we can have a self stigma, too. Internalized feelings of shame, low self-esteem, low self-efficacy. This is what happens with complications. All of us know that feeling, that warm wash of shame as it comes over you, as Brene Brown would say. Because when it happens, you feel like you're the only one who's ever experienced it, and it can be devastating. And then, of course, there's structural stigmas that happen, things that can happen if you have complications. You may feel a structural stigma to present in front of your colleagues, but it also may be an opportunity for growth. Just for a side here, I just included some of the mental health stigma. I don't think it's much different than complication stigma. You can get labeling, oh, they're a bad operator. You can be put aside, oh, I don't want to be around that. You can be devalued, discriminated against. I mean, I would say that probably there are physicians in each of our labs that perhaps staff don't really want to do procedures with. Now, that may be because they had complications. It may be that they're just a jerk, or it may be that they differ in some sort of opinion, or there's been some labeling. And remember, in a microcosm of cath lab, this can be a huge thing, depending upon how big your lab is and how many people are there. Even in a big lab such as my own, it definitely does occur, and there are stigmas that do happen. So I think it's really important to understand there are intrapersonal and interpersonal as well as structural stigmas that can occur. So that stigmas, let's look at the emotional burdens of complications and let's see how that ties in. Well, I couldn't help but put in at least a movie reference here or there, and those burdens of complications include fear. Oh my God, what's going to happen? What's going to happen to the patient right now? But what's going to happen to me? Am I going to lose my job? Guilt. I was entrusted with this patient's care and this happened to them. Anger. Why did I miss that? How did I miss that? Or worse, maybe you blame it on someone for distracting you. Embarrassment, of course, and we don't want to look bad in front of our partners or in front of our families. Humiliation. What about professional reputation concerns? What about reduced job satisfaction? You don't feel like you're very good at what you're doing on a day-to-day basis. You don't really want to go to work. You can lose confidence and also worry that you will continue to make errors. Many of us are perfectionists, right? And Brene Brown, I referenced her before. If you haven't read any of her stuff, I highly recommend it. When perfectionism is driving, shame is usually riding shotgun and fear is that annoying taxi driver. It usually all comes together. So I think it's really important from a side of an, as an operator, but also as a human to understand that these complications will happen and these emotions will come out. What are the prevalence? Well, how about you? It's a, it's not just a movie, but I'm going to ask you about the prevalence. What do you, each of you, have you felt this? I would say this number that I found in the data, about 30% of medical students, physicians, nurses reporting a personal problems related to an adverse event over the last 12 months. Well, I'll raise my hand five times over. I think over the last 12 months, I've had more than a few complications and I've seen those patients back in the clinic. In fact, just a few hours ago, I saw one. I thought to myself, I can't believe I did that. I can't believe that happened, but yes, those, those, those issues keep coming back and I would venture to say it's higher than 30%, but ask yourself. What about you? Are you having any of these reoccurring thoughts, memories, whatever it may be? And really what we're talking about here is second victim syndrome. For those of you who are not familiar with this, the first victim is obviously the patient who has a occurrence of a complication. The second victim is actually any healthcare provider, not just the operator, any healthcare provider involved in an unanticipated adverse patient occurrence who experiences psychological or emotional trauma related to that event. So it may not just be you as the primary operator, maybe your staff. It may be a nurse on the floor that, you know, really got attached to this patient and they have a bad outcome. You know, this can happen across the spectrum of those are on the healthcare provider team. And it wasn't until 2000, and I would say a little bit embarrassing that it took this long, until 2000, that Wu actually made this statement, medical error, the second victim, and there's been a fair amount of data looking at this, looking at surgeons more than anything else, and biomedic surgeons, interventional audiologists, addressing the second victim syndrome. Really, what is that phenomenon? What do we carry? And this article about the things we carry, the scope and impact, all of us know these complications. I'd venture to say most of us can remember all the deaths we've had in a cath lab, probably can remember every single instance of it. And really, when the doctor makes mistakes, needs help too. We are human. And the second victim syndrome really embodies what that encounters. Well, Albert Wu wrote this, and I'm going to paraphrase it, but I thought it made a lot of sense when I first read it. It said, we virtually all know the sickening realization of making a bad mistake. And I underscored what it feels like. You feel singled out, exposed. You agonize what to do. And later, the event replays over and over in your mind. You start questioning your confidence. Now, it goes on to say, you know, should you confess about it? And all of us have an ethical obligation to disclose these errors. I think, you know, going on about whether or not you should talk to him or not, but a lot of us can become overly attentive to the patient and the family, probably medically, legally being fearful. But I think when I read this, Albert Wu's initial statement in BMJ in 2000, I think, you know, we can all relate to this. Well, what does it do to you? Well, in one early study looking at about 32 patients who had second victim syndrome, the extreme fatigue was prevalent about 52% of time, sleep disturbances about 45% of time, rapid heart rate, increased blood pressure, muscle tension, rapid breathing. These all sound like PTSD. And this is another phrase or another form of PTSD. What about psychological symptoms? Well, you can read right through there, frustration, decreased job satisfaction, and go right down the list. This is in 32 patients in an article looking at what are the different stages trying to quantify what happens when we become a second victim. What exactly does occur? Well, if you say, well, that's 32 patients, that's really not a lot. Well, let's look at some data looking at a systematic review across several studies. Same thing's prevalent, troubling memories, almost 81% of the time. I still have them, still have them. Anxiety, concern, what about anger towards oneself, being frustrated with it? These are all important issues that happen to every single one of us when we have complications. And it's really important to understand that as we go forward and address that. Because if we don't name it, we can't address it. Well, what about the stages? In that first article, let's really look at 32 patients, or subjects, should I say, 32 of us that have had complications. What do they go through? Well, the first stage was chaos and kind of accident response. Let's take care of the patient right now. And I think all of us are pretty good at that. You know, someone had, I had a pericardial, I had a epicardial perforation. Okay, let's go into status mode, jump right in. Let's do a pericardiocentesis, let's autotransfuse, let's get the team going, let's get echo. All right, we do that kind of intuitively. All right, error recognizing, get help. And then stage two, intrusive reflections. Well, is it, how did that happen? Did I not pay attention? Did I oversize the balloon? Did I miss some calcium? And then stage three, looking at kind of like, okay, how does restoring personal integrity, like what will others think if I've had to use yet a papyrus stent? What does that matter? Will I ever be trusted again? Will this patient come back and trust me again? That's really important to understand. How much trouble am I getting in? Is it going to be an issue? And then we go into stage four, which is during the inquisition. I think this is kind of talking about the M&M, interacting with different levels of, you know, going debriefing, reiterating the case scenario, going through this and, you know, kind of what that impact is. Are you going to be brought up in front of the medical board? How is this going to pull out depending upon what that type of event was? And then of course, stage five, we have time obtaining emotional first aid. And I think really want to focus in on this tonight. How do you seek professional and personal support for each of these? How do you actually allow someone to say it's okay. You made a mistake and that's part of life. That's how do you get back on that horse and go out there and treat the next patient? That's a little bit harder to do. It's easier to say it's a little bit harder to do. And then you go through, you think, what did I respond to this matter? What's wrong with me? Do I need help? And then I think the last thing I really want to focus on are moving on. Because I think all of us have gone through these various stages and there's really a split here, right? You can either drop out, say I'm done, I can't deal with this anymore. You can survive or you can thrive. And we really don't have data on where people are going to go in this mess. We don't know who's going to drop out. We don't know who's going to survive. We don't know who's going to thrive. And so how do we get everyone to thrive? And I think that's more kind of what we're talking about today. It's understanding the emotional burden of what complications do. That's understanding the stigmas that happen to each and every single one of us. But more importantly, how do we get to the aspect that every single one of us, when we have our complications, will eventually get to the last stage and we will thrive, not drop out, and not just limp along as surviving. So I say, what can we do? And I think it's really important. Walt Whitman always said, be curious, not judgmental. So I think it's really important as we approach anything in life, but especially with complications, not just saying, well, how did this happen? Let's stop and say, how are you doing? How are you feeling? Yes, the complication, how are you doing? You're not being judgmental. So resist the primal urge to criticize. And we'll talk a little bit more about this with the next speaker. But I think it's really important to understand that we have to resist that primal urge to go on and criticize. It is innate in every single one of us. And I think we have to show some grace, really help and not hurt. Any of us, and I think all of us have had complications, know how bad it feels to be in that situation. The last thing you want is somebody to add some insult to injury. And then I think it's really important for each of us to do that deep dive, that self-work, so-called shadow work, and understand what works best for you. Some people love to talk out loud in groups. Some people love to be left alone for a little bit and work one-on-one with people. Ask what works best for your teammates. So if your partner has a complication, ask them how they're doing. They'll deal with the complication. And we talk about the technical aspects, but ask how they're doing. What works best for them? Approach with curiosity. Is it helpful for you to say, you know, someone would probably need to talk about this one-on-one or should we talk about this as a team? What's going to work best for you? And then expand our perspective of mental health disorders. We don't know what people are coming into each event with. We don't know have they had this before. Is this remembering or reminding them of something else? We don't know what their background is. So be curious, not judgmental. I think we also need to adapt evidence-based practices for decreasing stigma, I think, and discrimination in the workplace. I think we need to do this not only for mental health, but across the board. I think we need to really decrease stigma, stigmatization of anything more than anything else. Understanding that events will happen, and we can all try to get better. And it's all about getting better each day. We can really change our use of stigmatizing language. We can create a professional culture of caring. That's not necessarily true. You can't go back and change how perhaps your boss is, but you can create a culture around it, and culture trumps everything. Now, I like to say that we should normalize therapy, perhaps even have it be part of the culture post-complications. I would argue that maybe that's the next step. We all joke about, you know, the different generational changes. My kids, in their generation, in Gen Z, if you don't have a therapist, there's something wrong with you. And I think it's really important to understand that perhaps as we evolve as a profession, we will see more and more involvement of their professional counseling, professional therapy. And I think it's important because all of us do carry these burdens, and I would love to see more of that as we go forward. So, I just want to stop and just bring up three scenarios and just see how that has influenced you. Think about each of these, and I'm going to go through each and every one, and what's the first thing that jumps to your mind? So, 35-year-old junior attending, female attending, has a refractory no-reflow during PCI, VT storm, and the patient arrest. VT storm and the patient arrest. First thought, she doesn't know what she's doing. She should have seen that coming. You have a potential here for sexism, a potential here for ageism. Where did your mind go? Where did your thought process go? Ask yourself, honestly, where did you go with this process when you heard that scenario? Because you may help underscore or help reveal some underlying biases you might have. Or what a 57-year-old senior male attending has a patient during a CTO revascularization have an air embolism and arrest. Well, if you don't like this individual, maybe you're thinking he was sloppy, was moving too fast, he's impatient. Well, approach with curiosity, not with judgment. Or how about an older attending who misses a wire dissection, has stent thrombosis, and a chance for ageism. There's biases that come to your brain every single time you read each of these. And you may not realize it when it happens. But when I bring up these scenarios, it actually comes to fore. So, it's important for as you look at these and as your next complication occurs or your partner's complication, you stop the narrative. I think it's really important to stop the narrative and accept it as it is. It is a complication once the patient is stabilized and as safe or as good as it's going to get. Then we have to stop the narrative and approach with curiosity, not judgment. And so, this is what happens when narrative takes over, right? Things just quit making sense. The law of physics just takes a coffee break. And we start stopping. Logic goes out the window and it's more drawn. So, I think it's really important here to stop the narrative, pause, reflect on what's in front of you, and then move on. So, I found this, I had this in another talk about reducing mental health stigmas. Well, let's just change it and make it complication stigmas. So, here's some practical strategies to reduce complication stigma in the medical profession. Number one, I want you to normalize and just understand it's going to happen through open dialogue and sharing and talk about it so that you can talk with your partners, with your fellows, with your residents, or whoever might be on your cath lab teams and understand that this will happen. The second thing is to create a supportive, psychologically friendly work environment. If you normalize it, you create a culture where you're open and you're still going to love the person no matter what happens, just like your kids. They're going to make mistakes that you really don't want them to do, but they're going to make those mistakes. You have to understand that it's okay to be supportive of them. And last, review systemic practices that may perpetuate complication stigma and second victim syndrome. There may be practices in your own cath lab that make this maybe a grilling M&M where nobody wants to go to it because people are not nice and people try to pick out the details, whatever it may be. I think Bill talks about one where people yell at him when he was a fellow and you know not making you feel like you can't even know your own name. And I think it's really important to understand that there may be systemic practices, even in your own places, that you can resist and change. There actually is a program at Johns Hopkins University. I got to throw in some Atlanta Falcons, you know they're terrible because I hear in Atlanta about Rise Up. There's a program called the Rise, which is a peer-to-peer support for health care workers who've been experiencing a stressful patient-related incident or adverse event. That is a program that has a Rise team. That team has trained responders from different disciplines, social workers, nurses, physicians, chaplains, who actually can provide psychological first aid to peers involved in a confidential, non-judgmental environment. I think this is a wonderful step. I would love to see something like this at every single one of our hospitals and an idea that as each of us has our own complications, we not only have the support of our colleagues, hopefully, who approach with curiosity, not judgment, and our cath lab staff that we can all work together, but also as a system. Really build a system that each of us can be there for each other as we approach each in daily life, which has the mental challenges beyond comparing. I think what we do is very, very unique. I think what we have to deal with on a day-to-day basis is very unique, and I'm not taking away from any of our other specialties, but I think it's very important to understand and recognize that and that each of us will have some of this second victim syndrome at least at some point in our career. So in summary, complications will happen, period, end of discussion. They're going to have a major impact on each and every single one of us. None of us are robots. AI will not take over our jobs. It can't do stenting yet, but complications can be approached with grace, support, and curiosity, and hopefully, each of us can approach our next complication or our partner's complications or any challenges with those three things, grace, support, and curiosity. Don't jump to conclusions. Stop the narrative. Be the change that is really needed in your cath lab. It starts with you, and let's learn from each other. With that, I'm going to turn it over to my colleagues. I'm going to stop sharing my screen. Thank you very much for the opportunity, and thank you for tuning in.

emotional well-being

second victim syndrome

physician support

compassionate care

stigma reduction

systemic changes