Well, I'm excited to be here with all of you tonight and to embark on a two-part series where we're going to talk about some of the most powerful experiences that I think we have in a life in medicine and at the same time, some of the things we talk the absolute least about. We're going to be brave and this time, this month, we're going to talk about hard outcomes and in particular, I'm thinking about unexpected hard outcomes, although the expected ones take their toll on us too. Next time, we'll explore malpractice litigation and I'll share some information about navigating that process. But for tonight, we're going to talk about hard outcomes and us. I chose that title very deliberately because really what I want to explore tonight is what those hard outcomes mean to us, how we feel about them, how we can and do come through them, how they bring us together as physicians and as healthcare professionals generally. I want to start with an image. Let's see, for some reason, there we go. We're going to start with an image and a quote. This image is a picture taken from the International Space Station and what you're seeing there is the space shuttle as it has emerged from the clouds, as it's risen above the clouds. As we move along through this talk, you'll see why this image really speaks to me in this instance. I happen to have grown up on the space coast of Florida, can remember watching space launches from the beach as a young child and so the space program has always been interesting to me and a little bit near and dear to my heart. The quote comes from a physician named Elizabeth Kubler-Ross, who was a physician in the 70s. She became quite well known for her work around death and dying. Let's see, I want to make that go away. She became known for her work around death and dying and really became, I would say, the mother of the hospice and palliative care movement. She said, the most beautiful people we have known are those who have known defeat, known suffering, known struggle, known loss, and have found their way out of the depths. These persons have a sensitivity and an understanding of life that fills them with compassion, gentleness, and a deep loving concern. Beautiful people do not just happen. Tonight we're going to explore what kind of defeat, suffering, struggle, and loss we are prone to experience and how we find our way out of the depths. We're going to explore how we become beautiful people. So the experience that brought me to this topic was a very personal one in the course of my professional life. About 13 years ago, well, now that it's 2025, almost exactly 13 years ago, in the course of my work in the pediatric emergency department, I, on a Friday afternoon, saw a young woman, an older adolescent. She was 18 or 19 years old. She came in by ambulance. It was a very busy Friday in a small pediatric emergency department in a community hospital. We had a total of 12 beds in that pediatric ER. And it was a busy Friday right at the end of winter. This young woman came in by ambulance. She was assessed by nurses, very competent nurses. I took care of her over several hours, did an extensive workup, felt that she was stable to go home and follow up with her doctor on Monday. So after four or five hours, sat down, had a conversation with her and her mom, and we all agreed that she was good to go home. I talked with her primary doctor by phone, set her up to see them on Monday, and I discharged her home. And I went home myself. The next day, on Saturday, I came back at five in the evening to start an evening shift, busy Saturday evening, and no sooner had I gotten there than I was approached by a specialist from another part of the hospital who came to tell me that one of my patients, someone I'd seen the day before, was now in the ICU, and I couldn't figure out who it might be. Well, it turned out that it was this young woman. I had sent her home, and then that afternoon, on Saturday afternoon, she had arrested at home. Her family called 911, EMS came, they were unable to secure an airway, they took her to a freestanding ER near her home, where a very competent team also were unable to secure an airway, and they flew her to the ICU at the hospital where I worked. And in that ICU, this specialist, who was an ENT, secured an airway. You can imagine how my heart sank as he told me this story, because I knew that nothing good could come of this, it had been too long that she'd gone without proper ventilation. Even now, as I tell you, this story kind of makes my mouth dry and makes my heart race. I was devastated. As he told me this story, I got the sort of feeling I've had before when I've gotten a phone call that someone I love has died, sort of like a dizzy, out-of-body kind of feeling. I felt ashamed. I felt like I didn't want anyone to know, but I knew people had to know. I knew, you know, I was the assistant medical director of that little department, I knew my medical director needed to know. I felt grief for this young woman, for her family. I felt guilty. I didn't know what I'd missed, if anything, but I felt like she was there, I was there, I should have seen something. And for a long time going forward, I had sleepless nights asking myself, what if anything I should have done differently, and what if any responsibility I held for what ultimately became the death of a young person. Not surprisingly, about a year after she died, a lawsuit was filed against me. I was not the only physician who had seen her in a few weeks before her death, but I was the last. And so I knew that I would be seen as the weak link in the chain. So I wasn't the only defendant, but I was certainly the primary defendant, the lead defendant. The lawsuit extended over a period of about two and a half years, at the end of which I went to trial, and was at trial for about three weeks. So all together, a period of about three and a half years from the time that I first saw her, until the jury came back with a verdict. The verdict was almost kind of immaterial. The verdict was in my favor, but it didn't erase everything I had experienced and would continue to experience as I processed what had happened. About a year after I saw this young woman, while I was still sort of beating myself up over what had happened, and then had started beating myself up over the fact that I couldn't seem to shake it off, I stumbled upon an essay by an internist from Johns Hopkins named Dr. Albert Wu. Now, this essay had been published in the year 2000 in the British Medical Journal in response to a huge report by the American Institute of Medicine called To Err is Human. So this was a report on medical error generally. And Dr. Wu wrote this beautiful essay that spoke to me very deeply, in which he said, and although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors. They are the second victims. Nearly every practitioner knows the sickening realization of making a bad mistake. You feel singled out and exposed, seized by the instinct to see if anyone is noticed. You agonize about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence, but fear being discovered. I think part of what was so powerful to me about this essay was that this man, Dr. Wu, whom I had never met, put into words so perfectly what I had experienced. And that line, virtually every practitioner knows, I found that very meaningful. I thought to myself, you know, if virtually every practitioner knows these feelings, then they're not particular to me. This experience is embedded in the work. I subsequently learned that I believe Hippocrates knew this experience. We all have heard the beginning of his first aphorism, which starts, life is short, art is long. But I don't know that many of us learn the rest of the aphorism. It goes, life is short, art is long, opportunity is fleeting, experience is treacherous, judgment difficult. Seeing him use the word treacherous to describe what I take to be clinical experience is very poignant to me now. I was not actually the only person curious to hear what Dr. Wu had to say. After he published that essay, actually, a whole body of research exploded around the experience of what people came to call the second victim in health care. Now, I want to acknowledge before we go any further that this term, second victim, is a little bit tricky. Second victim is a little bit tricky. For some people, the word victim, you know, it feels open to misinterpretation and it can kind of push buttons for people. So I really want to clarify what I mean when I use this term. I'm using the word victim like I would in the emergency department refer to the victim of a car accident. This is a person who has been injured who needs to heal. It's not that the patient has victimized the practitioner. And it's certainly not that the physician or other health care professional has chosen to become a victim. I did not choose for what happened to my patient to happen to her. I was heartbroken by it. And I certainly didn't choose to feel as bad as I felt for as long as I felt that way. The other reason why I want you to know this term second victim is that if you want to go to PubMed to see that body of research, that's the term you're going to have to put in the search bar to bring up the information. But I do want you to understand there are good people at Johns Hopkins who use this term. There are good people at Harvard who do not like it. There are people in some places who feel very strongly that it somehow diminishes the patient's experience. There are other people who say, no, that's not true. We're saying this is the second one impacted. It's a ripple effect, just like sort of like blast injury and trauma, right? You don't have to be hit by the blast yourself to suffer blast injury. Second victims actually exist in many professions. They're not limited to health care. They also exist in all the fields where there are first responders. So firefighters, certainly EMS, the police are at risk of becoming second victims. The folks who work in aerospace and aviation are at high risk. Pilots are at risk. Air traffic controllers are particularly at high risk. In fact, the world's probably, I would say, leading voice on the experience of second victims is a man who's a safety scientist. He's originally Dutch. He now lives and works and teaches in Brisbane, Australia. And he is also a pilot. His name is Sidney Decker. And Sidney Decker says that a second victim is a practitioner. And he uses the term practitioner because so many kinds of professionals can be affected. A second victim is a practitioner who is internally injured. When someone they seek to heal or protect is harmed or just nearly so. And they believe they caused or might have prevented the injury. So I want to highlight a couple of things here. Those words nearly so. So the patient does not actually have to experience harm for a physician or nurse or their healthcare professional to be internally injured, to experience this occupational injury of this firestorm of emotion. For example, a nurse who almost gives an incorrect dose of medication may feel this way. A nurse who gives an overly high dose of a narcotic and quickly administers Narcan can have this experience. As physicians, if we catch ourselves in the midst of potentially a diagnostic error and correct our path just in time, we may feel great or we may feel some degree of emotional injury. Second of all, the physician or other practitioner does not have to actually have caused the injury. Simply believing we might have prevented it, whether or not we know we could have, is enough. So even after an autopsy, I cannot tell you why the young lady I took care of died. I don't know what happened. I do not know what happened, but I had this sense that she was in my ER. I should have seen something, so I was in that might have prevented the injury category. The second thing Sydney Decker has to teach us that's so valuable is what are the factors that second victims in every walk of life share? What do we have in common? There are two fundamental things. First of all, a deep personal commitment to the safety or welfare of other human beings. Second, work that involves high levels of complexity, often involving rapid-fire decision-making in the face of limited knowledge and significant unknowns. Doesn't that sound exactly like a life in medicine? Deep personal commitment to the well-being of others. Working in an area where we certainly have limited knowledge. We don't fully understand the human body and we probably never will. We're human beings trying to understand the human organism. Second of all, any given human body can differ from the norm in ways we're unaware of, right? We frequently find ourselves making decisions in rapid-fire ways. The hospital system, the healthcare system as a whole, is certainly something that involves high levels of complexity. When these two areas overlap, we sometimes get caught in the gears. Our commitment and unknowns and the complexity and all that, those two can collide. How do we feel when they collide? Well, sometimes people, they're okay. They're able to pick themselves up and say, wow, what can we do to avoid that happening again? But when the experience touches a person more deeply, kind of sets off an emotional experience, they may feel a sense of isolation, feel grief, shamed, guilty. All the things I experienced are exactly what the literature describes. People can frequently describe these events 30 years on in perfect detail. That's how powerful the impact can be on people. How do people who have this experience move forward? Well, there are basically three paths. First of all, I want to say that there is no judgment implied in any of these paths. Anyone who's coming through one of these experiences is doing the best they can. Second of all, I can speak from personal experience to the fact that people may not take only one of these paths. They may bounce around a little bit. They may, you know, limp along and survive for a while and then need to back away and drop out for a little while and then take a leap forward and they're thriving. So it can be a little bit of a hybrid experience. But to basically describe these paths, dropping out refers to stepping away from whatever environment you might have been in and changing gears. That can be very functional. It might mean, let's say, a nurse who's worked in the PICU setting for a number of years, has had some sort of cumulative experiences, needs to step away and move forward with their career in another arena altogether. They go to the GI lab, let's say. It could be a surgeon who's had one too many hard experiences in the OR, earns an MBA, enters the role of physician leader in a health system. There are a lot of different ways where people can functionally shift gears. But there are also forms of dropping out that we would prefer to help people to avoid. Those might include long-standing, unremitting PTSD or depression or addiction is not uncommon. Or in the very saddest scenarios, sometimes people drop out by taking their own lives. So we want to be aware that people are vulnerable if they're not finding their way forward. The second option is surviving and what the researchers mean by that term is simply a person who is sort of staying in place. They might be kind of limping along, putting one foot in front of the other, hanging in there, just doing the best they can. They're moving forward little by little. Then we have people who are thriving. Now what does that imply? Usually it implies a couple of things. That a person has found a way to connect with at least a small number of other people in a supportive way around an experience that was very hard for them. And second of all, the people who thrive will often find some kind of a way to take this really awful thing that happened to them or that they experienced, maybe we don't want to say it happened to them, it happened to their patient and them, and wring something good out of it. What our grandparents call taking lemons and making lemonade. Maybe that's a pharmacist who has a bad experience and gets involved with the movement to eliminate confusing drug labeling. Maybe it's a physician who feels quite clear about their diagnosis when they go into a procedure, finds the patient is the one in a million who doesn't fit in that basket and has some kind of a rare condition or diagnosis, and they commit themselves to teaching residents about that diagnosis. It can be parents or families or health care workers who work together to create some kind of a not-for-profit endeavor to support people with a particular condition. I want to take us way outside of medicine for a few minutes because part of what I want you to take away today, if it's not clear already, is that this is not just a physician experience, it's a deeply human experience. We're going to take a few minutes and I'm going to play you an NPR story. These fellows in the picture, the one on the left is the person we'll hear interviewed. His name is Wayne Hale. I want you to listen to this story because it's not a story of medical decision-making that we're talking about. It's a story of human decision-making and human living, human growth. We're going to hear Wayne Hale's story and as you listen to it, try to think about the things we've just been talking about and we'll come back to them, like who are the people this happens to, the second victim experience, what are the factors that set them up for it, kind of how do they feel, and what do they do next. We tend to mark our successes in life but what if we're thinking about it the wrong way? What if it's failure that shapes us? All this month in a series we're calling Total Failure, we will examine mistakes and how they change people's lives. Today, NPR's Jeff Brumfield brings us the story of Wayne Hale. He's an official at NASA who was involved in one of the agency's greatest failures, the loss of the Space Shuttle Columbia. On the morning of February 1st, 2003, the Columbia was supposed to come back. Wayne Hale was at the landing site at the Kennedy Space Center in Florida. Wayne was an up-and-coming manager with NASA who'd just taken a job overseeing shuttle launches, but since today was a landing, he didn't have much to do. Really, it was kind of a party atmosphere out there. He and the other managers were hanging around in the grassy viewing area near the landing strip. Families of the astronauts were there too. Loudspeakers were playing communications between Columbia and Mission Control. Columbia continuing toward Florida, now approaching the New Mexico-Texas border. Wayne was chatting with his friends and feeling pretty relaxed. The astronauts were scheduled to land any minute. And I really was not paying a bit of attention. Columbia-Houston, we see your tire pressure messages, and we did not copy your last one. And finally, somebody, and I can't remember who, said, isn't it unusual for them to be out of contact for so long? And I looked over at the clock, and I said, you know, to myself, I thought, no, this is really unusual. Not to have communication with the crew at this point is not good. There is something seriously wrong. That's the first time I thought we were in real trouble. Wayne and the others rushed back to the main buildings at the Space Center. By the time they made it, the television was already showing footage of the shuttle streaking across the sky, breaking apart with seven crew members inside. It was just, I mean, a very low time, really bad. Wayne had spent his entire adult life in the space business. He knew it was dangerous, but NASA had the smartest engineers, the best rockets. I mean, I thought our organization was great. I thought we could handle anything. Wayne and everyone at NASA that day felt an incredible sense of loss and also of failure. Our job is to keep the crew safe, and they weren't safe, and that's an immediate failure. Now you're just asking, in what way did we fail? Trying to answer that question changed Wayne's life forever. To understand how that happened, we need to go back to the day after the launch, when an engineer who worked for him, a guy named Bob Page, walked through his door. Bob comes into my office and said, hey, we had a debris strike on the orbiter, and I've got this video clip. Let me show it to you. He popped a CD into Wayne's computer and pulled up the clip. It showed something fuzzy coming off the shuttle's big orange external fuel tank. The object smacked into Columbia's side. Somewhere in kind of the left wing area and went poof. Pretty much right away, Wayne knew what had happened. The big tank is covered in foam insulation. Some of that foam had fallen off and hit the shuttle during liftoff. Wayne and the other managers had meetings to look at the incident, and in the end, they decided, yeah, this is not a problem. The bottom line was, we all felt pretty good. This is not going to be a safety issue. We're going to have to do some maintenance work, but not a safety issue. And that's what we told the crew. You know, that's what we all thought. Foam had been striking shuttles every now and then for years. It had done some damage in the past, but not too much. This time was different, though. On this fateful flight, the foam punched a small hole in the left wing. When the shuttle reentered the atmosphere, hot gases seeped into the hole. The aluminum frame melted. The wing buckled. The shuttle broke apart. So the wing failed because the foam failed. But for Wayne and NASA, that was not the real failure. All real problems are people problems. It's not, you know, did the foam come off the tank? It's why did people let the foam come off the tank? Why did we think it was okay for foam to come off the tank? Remember, he'd known about the foam problem for years. He'd been in meetings where he could have said, hey, this looks dangerous. There were a hundred times I could have stood up. And would it have made a difference? Would people have listened to me? I think they probably would have. I was senior enough. So yeah, I feel like this was probably the worst failure of my life. Why didn't you? Why didn't you stand up? Well, you need a psychiatrist for that, I guess. I mean, I didn't think I needed to. I mean, I didn't think of it. I wasn't smart enough. After the accident, an official investigation found there were some smart people at NASA who were worried. Engineers lower down in the shuttle organization had discussed problems with the foam many times before, but their concerns weren't clearly understood by people at the top like Wayne. We've got an awful lot of smart people in the space program, but many of them are not very good communicators. And managers had a lot to worry about. They needed to keep the shuttle program on schedule and on budget. And there were always problems that needed fixing. So if an engineer couldn't explain an issue clearly, it got ignored. If somebody brought a concern to you and it was not, you know, it just didn't sound logical, you were very dismissive of them. Basically told them to get a life. After the accident, the heads of the shuttle program were removed. And in a strange twist of fate, Wayne Hale was promoted to second in command of the entire fleet. How can this be? You know, we screwed up. We failed. We made this big mistake. I was in the middle of it. And yet, you know, they put me in a higher position of authority. So you talk about feeling guilty. Now there is something to feel guilty about. Part of Wayne's new job was to fix the cultural problems at NASA, and he resolved to start right away. He said the first thing we've got to do is we've got to put the arrogance aside. Wayne became a listener. When an engineer came to him with an issue after the accident, even if he didn't understand it, he tried. I really had to take a step back and start creeping people with, OK, you've got this concern, I don't understand it. Back in the old days, I would have yelled at you, but you don't say that. And now I have to really think about how I get you to give me some more information. Wayne oversaw many of the shuttle flights after the accident. It did not fail again. He says they made plenty of changes to checklists, but he thinks the biggest change was that everyone who worked at NASA became better at talking and listening. Jeff Brumfield, NPR News. Such a powerful story, such an amazing story, and in so many ways on so many levels. When I hear him say it was a party atmosphere, we were chit-chatting out on the tarmac. It was a party. I don't know how it is in the cath lab, but I can tell you sometimes it's a little bit of a party in the ER. If somebody comes in at midnight on Thursday evenings, it starts passing out Twizzlers, right? Definitely a little bit of a party atmosphere. And these events can sort of sneak up on you that way. It's not that we shouldn't have a party atmosphere. We need to be in the flow, in the work environment. I was struck, and I'm always struck, by how he tells what happened, and then you hear in his voice the sadness when he says, it was a very low time. I definitely get the feeling he's moved beyond these events, and also, he can go right back to it in his heart and mind if he pauses to do it. He says, it was our job to keep the crew safe, and they weren't safe. And then the other thing that I think is so beautiful in his story is how ultimately what he comes around to in terms of one of the paths to thriving or to growth for him is we had to set the arrogance aside. I think as physicians, we can sometimes get ourselves into trouble when we're frustrated, tired, maybe feeling a little bit burned out, maybe feeling too pressured. We don't pause to truly hear what a nurse or respiratory therapist is trying to tell us. So let's just quickly look back at a couple of these slides. You can see in Wayne Hale the person who's internally injured when a crew he sought to protect was harmed, and he believed he might have prevented the injury. You can hear his deep personal commitment to the safety or welfare of other human beings, and you can hear the work involving high levels of complexity, often involving rapid-fire decision-making in the face of limited knowledge and significant unknowns. And the thing that's tough about significant unknowns is sometimes they're unknown unknowns, right? He thought he understood whether there was or was not a risk in relation to that phone, but it turned out it was an unknown unknown. His form of thriving, like we said, he certainly started to focus on communication, setting the arrogance aside. I'm imagining that in that kind of environment, not entirely unlike medicine, frankly, you probably have a wide range of personality types and some neurodiversity. You've probably got some people who are very verbal, and he said some of these other people are very verbal, and he said some of these others, they weren't great communicators, but I mean, clearly they got their jobs somehow, right? So they clearly have significant knowledge. So learning to hear those people better is an important piece of what he took away, and I would say that is important to our work insofar as communication and setting arrogance aside frequently can prevent those unexpected outcomes that result in this difficult experience for us. Now, I want to look a little more at the nitty-gritty of the emotional process, what we experience, and how we address it, you know, directly. First of all, guilt, shame, and grief are like the top three things people experience. I want you to know that those emotions reflect compassion and the pride we take in the work we do. The more committed we are to that work, the more compassionate we are in relation to our patients, the harder we will feel adverse outcomes. There's a little bit of an old-school culture in medicine that leads us to believe these things should roll off our backs, like, it happened, that was yesterday, this is today, on I go. It often doesn't happen that way for people. It doesn't roll completely off our backs, and the reason that it doesn't is that we actually genuinely care. Second of all, responsible people take responsibility, even when they have committed no wrong. Responsible people take responsibility for what happens in their cath lab, or their OR, or their ER, or their office, and frequently we beat ourselves up when we can't shake these feelings off. I want to go back to Albert Wu for a second. He says in the same essay I mentioned before, in the long run, some physicians are deeply wounded, lose their nerve, burn out, or seek solace in alcohol or drugs. My observation is that some of our most reflective colleagues are perhaps most susceptible to injury from their own mistakes. When I read that, it was like a eureka moment, because I know that being reflective, being self-reflective, is in fact identified as one of the essential qualities of the excellent physician. So, the fact that I was hurting was in part because I am reflective. We certainly don't want all the reflective physicians to leave the profession, right? When I saw that connection, I started to see just what we were talking about, that being compassionate is part of why we hurt. Another classic quality of the excellent physician is diligence. If we're diligent, it hurts when things go wrong, right? If we have high integrity, it hurts when things go wrong. So, the fact that it hurts is not a sign that you are not cut out for the practice of medicine, which is what many of us feel after an event like this. On the contrary, it's a signal to you that you are exactly the type of person cut out for the practice of medicine. Let's distinguish between guilt and shame. Guilt is a sense that I did wrong. I made a mistake. Shame is the sense that I am what is wrong. I am a mistake, and you could see how that line of feeling could go very wrong. It is an absolutely human experience, shame. So, don't shame yourself over feeling ashamed. That is not helpful. How to address guilt. First of all, we want to seek forgiveness, when that's appropriate, from a patient, from a family, maybe from co-workers. You might have a situation where an ordering physician, a pharmacist who mixed a drip, and a nurse who hung the drip all need each other's forgiveness. I want you to vigorously pursue self-forgiveness in whatever form that takes for you. It might be prayer. It might be meditation. Whatever it takes. And I want you to seek a positive outlet. Seeking the positive outlet is the kind of things we were talking about. Taking that difficult experience and trying to bring something beautiful out of it. Shame, on the other hand, is addressed differently. That sensation that I am the mistake in this equation. I am the mistake. It's a very human experience. It dwells in isolation. It drives us to want to isolate ourselves and, contrarily, connection to others is what promotes our healing. Brene Brown, who many of you may be familiar with, has a PhD who has done extensive research into the human experience of shame. She says that the cure or the solution for shame is to find someone who has earned the right to hear your story and tell it. So who is it who's earned the right to hear these hard stories in our lives? It might be another physician or a nurse who you trust to listen with an open heart and be supportive. And if the person you tell cannot be supportive, you have not found the right person and you need to try again. I want you also to honor these stories as one of the many ways in which we as physicians are connected. You may feel like your experience sets you apart, like you're the bad apple in the barrel. That is not the case. Your most respected mentors are likely to have had these experiences. What do we need when we're injured in this way? We need to know we're not alone. We need a safe space for conversation. We need some assurance that we can heal and even grow. We need to understand our situation. We need time to navigate the emotions and our path to growth. And we need education and support through any aftermath. You know, sometimes things like morbidity and mortality conference or peer reviews or lawsuits, they're a painful aftermath and we need support through those things. So I want you to start from this day forward keeping your eye out for the people around you who might be having this kind of experience. Some of them will keep it pretty well hidden, pretty well under wraps. But as you think about what the factors are that lead people to have this emotional experience, you may start to notice, oh that person might be, you know, might be hurting a little bit. Let me check in with him or her. Sydney Decker, the pilot safety scientist we talked about, the researcher, says that ultimately social support was the most important variable in determining whether a clinician would drop out, merely survive the experience, or actually grow and thrive, experience what psychologists call post-traumatic growth. If you take nothing else away today, I want you to take away that social support is the most important need people have when they're recovering from heart outcomes. Oops, hang on. I want to take us to another story all together just for a minute. Many of you will recognize that this is a painting featuring George Washington. This is called Washington Crossing the Delaware and there are several originals of this painting in several places, but one in particular is at the Metropolitan Museum of Art in Manhattan. And it is immense. It is immense. It is like 20 feet tall and 40 feet across or something like that. It is gigantic and is in a room all of its own. It was painted well after Washington's death and clearly, you know, celebrates him as a hero. The musical Hamilton by Lin-Manuel Miranda puts really beautiful words in the mouth of George Washington on several occasions, and there's one moment that really touches me where George Washington says, in reference to an actual experience that George Washington did actually have when he was the age of your average medical student, he says to Hamilton, I was younger than you are now when I was given my first command. I led my men straight into a massacre. I witnessed their deaths firsthand. I made every mistake. I felt the shame rise in me and even now I lie awake knowing history has its eyes on me. Let me tell you what I wish I'd known when I was young and dreamed of glory. You have no control who lives, who dies, or who tells your story. That particular piece speaks to me so beautifully because what it says to me is that we experience someone like George Washington as a hero, not because he was a perfect man, and in fact his journals reveal that he understood that he wasn't a perfect man and that he experienced deep moral conflicts in his lifetime, which he did not find a way to resolve. You can see in this painting that he is in fact in a situation involving high levels of complexity, right? They're crossing the Delaware River on, I think it's December 24th. They've got ice all around them. Everyone's looking in every possible direction. He is looking to the other side of the river. He's the one trying to see all the way across. There are horses on some of those boats back there. It's like a little bit chaotic, right? But he is looking all the way across and they're heading over in the interest of much higher goals. I think that's why we see him as a hero, because he's willing to go into these situations of great uncertainty, make rapid-fire decisions in the face of significant unknowns, all for a higher value. I think that you, as physicians or other health care professionals, are that kind of hero. I don't think it's that you should feel that you're willing to sacrifice your life going into work. I think though you are the kind of person who had a deep commitment to something greater than yourself, willing to put yourself in the position of confronting high-complexity situations, sometimes making rapid-fire decisions in the face of significant unknowns, and at the risk of some kind of harm, sometimes coming to yourself along the way. It's my hope that if you've had an experience like the one I've described, or if and when you do, you'll stop and give yourself the grace of recognizing that you are an unusual kind of person. You're the best of humanity, and it hurts only because you're the best of humanity.

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second victim

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social support

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