Thank you very much, Dr. Mangalapudi, I appreciate the opportunity to be here with everyone. So what really is burnout? Well, burnout really is emotional exhaustion that's caused by prolonged excessive stress. And it can be mental, physical, or emotional. And when we get to that point where you're just exhausted, in any of those ways, you're pretty much going to be burned out. Next slide, please. So burnout doesn't just affect cardiologists. It affects really the workforce, and this is some data that comes across from the general population of people who work, essentially. And it says that, well, what causes burnout for the average worker? Well, the stress feels never-ending. There's no control over how the job's done. It requires tasks that conflicts with what you really want to be doing. And you end up working toward a goal that really doesn't resonate with you. When you're doing that over and over and over again, and you have a lack of support from the infrastructure that's there to help you get your job done, that can cause burnout. But let's look next, on the next slide, at how we can relate this to cardiologists specifically. So the American College of Cardiology, back in 2019, collated a study where they surveyed a little over 10,000 cardiologists and got about 2,100 responses. So this is about a 20%, 21% response rate of cardiologists to this. So it may not be completely representative, because obviously people who were more concerned about burnout may have been more likely to fill out the survey. But I think it does create some interesting points for us to look at. And the first is that 19% of cardiologists who responded to the survey reported occasional burnout, 6% said it was frequent, and 1% said it was serious enough that they were actually seeking help for the burnout that they were experiencing. So what are the risk factors for being burned out in cardiology? And this is, again, from this study by the American College of Cardiology. If you can just go back one slide, please. There we go. What are the risk factors there? So really, it was being not compensated appropriately for the work that you were doing, family responsibilities hindering your professional work, you weren't able to achieve your professional goals, mid-career physicians reported burnout at a higher rate than early and late-career physicians, feeling not fairly treated at work, being not valued for your performance and your input, females reported more symptoms of burnout than males did, and again, dissatisfaction with family life played a role there. So this work-life balance does come into play when it comes to developing burnout. Next slide, please. So what are the signs of burnout? What should we be looking for in ourselves and maybe seeing in some of our partners there? Well, first, feeling overwhelmed, emotionally drained, and really unable to meet the constant demands. You're frustrated, basically. You're losing interest and motivation in what you're doing. You're cynical or resentful. You feel like you have nothing more to give. You really can't maintain that work-life balance. You're removed from your work, basically. You don't feel connected to the people who are involved and the people that you're working with. You're listless, tired sometimes, lacking the energy to do the job well, and frankly, in some cases, not caring for doing the job well, just assuming that because you know how to do it, it must be getting done well to start with, and feeling at the end of the day that there's very little satisfaction, that you're kind of taken for granted, and you're just maybe a cog in a wheel there. You're not really contributing to the success of the enterprise that you're in, and ultimately, maybe even doubting your skills and abilities. Next slide, please. So what symptoms might we find in people who are experiencing burnout? Well, chest pain, palpitations, dizziness, fainting, and headaches have been reported, and that was, again, from this American College of Cardiology survey of physicians who reported that they felt burned out. Next slide, please. So let's look first, again, at how we get to burnout and what precedes that, and what we can do to kind of prevent and understand where we're getting into it. And I think this is a very useful bell-shaped curve. It looks at pressure versus performance. It's sometimes called the stress curve. And at the far end on the left there is what's called bore-out, and bore-out basically means you're in a very low-pressure situation. You have very little performance, and so you really feel not challenged by anything. And that's not a good situation either. That may be something that you can be a little couch potato and watch TV for a while, but after a while, you really want to feel like you've got something to give, and you want to be challenged, you want to be able to do something. So the next step really moves into the ideal zone, which is the comfort zone moving into what's called the stretch zone. So the comfort zone basically is where you feel like you're challenged. You have to be thinking about what you're doing, but you don't feel stressed about doing it. An analogy I would think, myself at least, would be doing a diagnostic cath. So that's something extremely comfortable with, not really a high-pressure situation, but you do have to be focused, you do have to be attentive to what's going on. But it's not the highest stress situation. But to really feel you're getting your best performance, optimal performance, you really have to move into the stretch zone. And I think for us as interventional cardiologists, that may come more into play when we're doing an intervention or a structural procedure where the odds are higher that we may run into complications or face issues that are going to be more challenging that we really have to think more about. And every action we've got has maybe a little bit more consequence than basically doing a diagnostic study. So that really may be the optimal performance zone for us. We're focused for that period of time, thinking of nothing else. And I know, at least for myself personally, I really have a low attention span. I've been told that all my life from first grade on, but when I'm in the cath lab, nothing else matters. Nothing. Nothing else can be going on. I'm just focused on that. I don't know how that occurs. But I think for most of us, that really pretty much is the case. That's all we're concerned about. But it can be too much of a good thing. And I think strain is where we start to then move into the area where we need to start being concerned. And strain, for example, might be all you're doing all day long are high-risk cases. And you're doing that over and over and over again. Well, you might think at the beginning, hey, I'm this really great person. They need me in there. They need me to do this. I'm the most valuable player you've got in the cath lab there. So of course, I'm going to have to be in there doing these things. But realistically, if we continue to do that over a long period of time, it weighs on us. And it weighs on us in ways that we see fatigue, frustration. We may lack concentration at some points. We're not as focused as we used to be. But psychologists have said that we create what's called the zone of delusion when this happens sometimes. We actually think we're doing better. We think we're more important. We think we're more focused, when in fact, we're really not and may take somebody else to tell us that. So that's the zone of delusion. And then if there's too much of that strain, in other words, if we're doing that all the time, and to take an extreme example, it might be somebody who's covering ad hoc PCI all day long. You've got invasive cardiologists doing your studies. You've got eight cath labs. And all you do is go from one high-risk PCI to the next over and over again all day long. If you got to that point, you're too strained, and you're going to get burned out. So I think there's really a continuum there. We want to find a happy medium. The happy medium is the comfort zone, the stretch zone. We can get into the strain zone. But once we get into the strain zone and stay there, then we're at high risk of getting into the burnout zone. I should say also, this is going to be different for different people. There's no such thing as one-size-fits-all here. There's folks who really are going to be strained even in a comfort zone somebody's very comfortable in. Other people may say, that's my strain zone. So we each have to learn where our happy spot is in that there, and not really step and try to judge what other people are doing there, but look within ourselves to see where we are in there. And if we have colleagues that we see are having problems and asking questions of us if they need help, stepping in and try to put it into this kind of context as to where they are and where we hopefully can get them back to be. So that's a short introduction to burnout. What the risks are for burnout, what the symptoms are of burnout, and where really stress fits into what we want to have as pressure, but not too much pressure. It's a great talk. Thanks, Dr. Duffy. So I may just pitch the question to some of the more senior folks. I say senior, but just in terms of being in practice the longest, maybe Peter, Hari, and Ajay. How do you think interventional cardiology has changed since you all started to now? And do you think there's more reason to burnout these days, or was it worse in the past? And how do you see the field moving forward? I can start off, and then I'm interested to hear what Peter and Ajay say. Look, I think the field has gotten difficult. I think if you look at different things that have gotten better, some things have gotten worse. Our techniques and tools have gotten better. So in some regards, things are better in terms of procedures are quicker. But that being said, we've gotten into more and more complex procedures. Coronaries have become more complex, there's more imaging, there's more physical stress on the body. And we're all realizing that. I also think that what we're willing to deal with has changed over time as well. And some of that first generation of people going into this field, they had that exuberance, but it wasn't as much volume and complexity as we have now. So I think the other thing that's really happened is the EMR and the complexities of how the systems work and that everybody's employed by hospitals. So we have much less autonomy over our well-being. And so that all plays into the stress. I think what Peter mentioned is loss of autonomy and not feeling like you're doing what resonates with you, or that your mission is aligned with what you're doing. And I think those are all the causes right now that I see have changed more frequently now than what we had back in the past. So some of my initial thoughts on this, but Peter and Ajay. Yeah. I mean, look, I think that it's, for me, the biggest factor is the way that administrations and compensation schemes are set up these days. Our view systems, which I think are like the bane of everyone's existence, frankly, contribute a lot. And I think that the human element of what we do is something that people sometimes forget. And if you lose that element, then it's just a job. And it's not a great job when you're putting patients' lives at risk at times. So I think that if you lose that human element, that's the biggest way that I think the burnout bug really starts getting on you. And you have to then put aside a lot of the administrative hassles and struggles and everything and still get your way to that human element in a way to sustain yourself, especially over a long career, because the novelty of whatever you're doing kind of fades a little bit. Like you know how to do a basic PCI and that doesn't change. It becomes pretty straightforward. You can add new tools and toys and things like that, but it's going to get mundane after a while. The human element is the thing that sustains. Just to add to that, that I think what Harry's alluded to and Audrey's spoken of as well, is we've got, we always say sicker patients, but there really are sicker patients. We've got people with much more complex medical conditions that we have to deal with now. So we have to be thinking about when we take them to the cath lab. We're doing higher risk procedures. We're taking a lot of people with shock now from the emergency room right to the cath lab there. So a lot sicker people. And the point then becomes expectations are a lot higher. Expectations now are, if you make it into the hospital, the cardiac arrest, well you're going to walk out the next day. And if you don't, what was wrong with the cardiologist that took care of you? We've all experienced cases where you go and do a diagnostic case and you have to tell somebody they need surgery and they look at you like, what kind of doctor are you? Nobody gets surgery anymore. Everybody gets stents. Why can't you just put stents in and fix that whole thing? So our expectations are higher, and then thanks to the great work that Sky and Harry's done on shock, for example, expectations are higher that people are going to survive shock. Well, they didn't survive. They just didn't survive. Now you're under a microscope as to, well, let's go through exactly what you did through this entire procedure to figure out, you know, could you have done something better? And it's a great learning experience, but it also puts us under more stress because we're under more of a microscope with our colleagues looking at that. I think that's a good thing, but it does create more stress. Back 15, 20 years ago, we didn't have all these registries watching us, public reporting and these things, and it is very true that we're doing sicker patients because Ajay and Peter and I can remember when the shock trial came out and for a while we were not doing anybody over the age of, I think, 75 because the registry data showed that we were hurting them. Think about that. 75 was considered too old to intervene in what we'd consider a very high patient. Now that moved to 90 years old, so it's very common we're doing 75 to 90-year-old patients all the time, and so we're operating on a stress level that's very high, superimposed by registry data, quality, EMR, medical-legal, all these things that are much worse now, I think, overall than they have been in the past, and that's just a clinical aspect. We haven't talked about balancing your life and making sure you find happiness in other ways to prevent burnout. Maybe I can ask Don about the internationalism, international perspective. I know you were the sole operator there in your practice for a long time. Did that burn you out? How did you cope with things? Well, I kind of give my personal story in my talk coming up, but most of my frustrations aren't really the stress of being in the cath lab because I actually do very simple stuff. It's actually making my cath lab take over. It's figuring out the supply chain, figuring out equipment issues, dealing with administration, dealing with procurement, nursing. That is a huge part of my frustrations, and then it's not just the cath lab either because the majority of my practice is actually general cardiology, and it's being one of four cardiologists in a public health system for the whole country, so it's a lot of work in general and a lot of frustration, but I expand a little bit more on it in my talk.

burnout

cardiology

emotional exhaustion

work-life balance

stress management