Allison DuPont here from Northside Hospital System in Atlanta, representing the Sky Well-Being Committee. We have some of our other Sky Well-Being Committee members here today to have our third Well-Being Webinar, which is Tackling Grief and Depression. For those of you who did miss the first two, they are recorded, so you can access those. This one also will be recorded. First, I'll introduce our speakers and our panelists. First, Dr. Kechi Ijeoma from the Ohio State University is going to be presenting for us today. Dr. Dawn Scantlebury from Queen Elizabeth Hospital in Barbados. Dr. Lyndon Box from West Valley Medical Center in Idaho. All of them are our speakers. Dr. Dan Kalansky from the Hospital of the University of Pennsylvania. I believe my partner, Dr. Jeff Marshall, is trying to join now as well as a panelist. Dr. Dan Kalansky and Dr. Jeff Marshall will be our panelists. I do encourage everyone to enter any questions into the chat box. We will be checking that regularly. We do plan to have a discussion at the end of all the presentations and answer any questions that you might have. If there are any questions that we can't answer, then we will find the answer for you. Let's go ahead and get started with our first speaker. Dr. Kechi Ijeoma is going to speak to us about personal grief, professional grief, and the second victim concept, am I immune from this? Well, thank you, Allison, and welcome everyone to this webinar. I'm Kechi Ijeoma, an assistant professor of interventional cardiology and telemedicine at The Ohio State University. I have no disclosures for this slide set. Our objectives are fourfold. We are going to define the terms personal grief, professional grief, and second victim. We'll describe the symptoms associated with second victim syndrome. We'll review the risk factors for physician suicide, and then we'll discuss strategies to promote mental well-being. Let's talk about grief and second victim syndrome. Here's a case for you. You have a 35-year-old interventional cardiologist who recently experienced a divorce from his spouse. He demonstrates irritability, anger, and patient behavior in the cath lab. Prior to divorce, he was known to work long hours in the lab and was always happy to take on the last case of the day. So what is this interventional cardiologist experiencing? Is it personal grief? Is it professional grief? Or is it second victim syndrome? While you're thinking about that, let's move on to the second case. We now have a 33-year-old interventional cardiologist who comes home after performing a complex high-risk PCI. The procedure was complicated by coronary perforation, pericardial tamponade, and cardiac arrest. Despite multiple attempts, the patient died. Interventional cardiologist gradually becomes withdrawn, demonstrates irritability and anger, and is often heard making several self-derogatory remarks. So the question is, what is this interventional cardiologist experiencing? Is it personal grief? Is it professional grief? Or is it second victim syndrome? So let's talk about grief. Grief is a natural emotional response to loss. Whereas personal grief describes the grief that someone experiences when someone has died in their personal life or in their community, professional grief describes the grief that's experienced by professional care providers or caregivers after the death of a patient. And so healthcare providers are often described as distant mourners because they typically take care of patients. And when sometimes our patients pass away, we may experience grief. That is professional grief. And the response to grief can be unpredictable and idiosyncratic. Kubler-Ross described five stages of grief, Kubler-Ross described five stages of grief, denial, anger, bargaining, depression, and acceptance. But it's important to recognize that the stages of grief are neither linear nor exclusive. Neither is it distinct or set in number. For example, someone may not necessarily go through all five stages of grief. And sometimes a person could have two or three stages occurring at the same time. And some people may not even have all five stages of grief. They may just go from denial and acceptance and then back to regular lifestyle. Dawn, can you turn your video on? Some people are saying that they can't see you. I'm sorry. Sorry to interrupt you. Can you see me? I mean, catchy. I'm sorry. Well, my video is on. You can't see me? Okay. I can see you now. I see you. Okay. Perfect. So, second victim syndrome and second victim, these two terms... So, when there's an adverse patient event, the first victim refers to the patient, whereas the second victim describes a healthcare professional who's involved in the adverse patient event and is traumatized by the event. So, once again, first victim is a patient who's involved by the event. And then the second victim is the healthcare provider who was involved in that event and is now traumatized by the event. Second victim syndrome describes a range of emotional and behavioral responses which affect both the personal and or professional life of the healthcare provider involved in the event. The meta-analysis was done looking at the prevalence rates of psychological and psychosomatic symptoms in second victims. And what was found was that the top psychosomatic and psychological symptoms included troubling memories, anxiety, anger toward oneself, distress, fear of future errors, anger, feelings of inadequacy, and reduced job satisfaction. Another study was done also looking at the categories of emotions experienced by healthcare providers after adverse or traumatic event. And once again, anger and the fear of insecurity were the top mentions. Negative self-evaluation by the provider, guilt and shame. So we keep hearing that recurring theme, that anger and feeling of inadequacies are the top emotions. What are the consequences of second victim syndrome? Well, if second victim syndrome is not properly addressed, it can lead to symptoms of post-traumatic stress disorder, it can lead to job turnover, and sometimes the healthcare provider may actually leave the profession. And the worst case scenario, which we never want to hear about in anybody at all, is suicide. Let's talk about suicide. Some facts about physician suicide and suicidal ideation. We know that physicians are at higher risk for death by suicide, and physicians have occupation-specific risk for suicides. We know that physicians that have suicidal ideation are more likely to be younger, female, unmarried, childless, and in practice for a short time. And physicians who thought they made a major medical error in the preceding three months were nearly three times more likely to experience or report suicidal ideation. Although meta-analysis and reviews have shown that suicidal rates amongst physicians have decreased over time, studies have shown that it remains elevated for female physicians. What are the factors that can contribute to physician suicide? Well, significant stress and burnout, being involved in a medical error or malpractice suit, psychological illness, work-related problems, relationship issues, or financial issues. So how do we promote mental well-being? Some strategies, both on the side of the healthcare provider as well as on the side of the institution, include incorporating mental health education for our healthcare providers, enhancing support networks for our healthcare providers, implementing a flexible work schedule so that people can adapt their work schedule according to the levels of things they may be experiencing in their personal lives, reducing the stigma of mental illness in healthcare providers, re-evaluating the medical licensee policies to ensure that physicians who want to seek mental health care don't face jeopardy on the licensure or recertification, and making sure that we have a cultural shift where the mental well-being of the healthcare providers is emphasized, and building that community of support. So back to the question of this section, personal grief, professional grief, second victim syndrome, are we immune from this? Well, to get immune from this, we have to commit to self-care. So we have to learn personally to balance our work demands with our self-care. We have to give attention to our healthcare maintenance, cultivate healthy coping skills, good eating habits, regular exercise, mindfulness training. It's important as individuals that we recognize when we're under stress, identify our stress levels, and know when we're getting close to burnout. We don't want to get to burnout, so when you realize that your stress levels are going high, recognize it, and adapt strategies to reduce your stress levels. And then seeking appropriate professional help. So counseling and psychotherapy, if you've reached a stage where you know your mental health is impaired, you should definitely reach out for professional help. And if you have a physical disorder, don't ignore it. Even though we take care of other people, we need to take care of ourselves, so seek treatment for physical disorders. Other things that we can do to help us be immune from the bad negative effects of second victim syndrome, developing a personal support network or a community of trusted individuals, engaging with your faith community, and if your institution does not have wellness programs, reach out to your leadership and ask for those programs to be developed at the institution. And then participate in professional development programs. You should know where you are in your skill set, and if you need new skills or to develop your skills, reach out and get those professional development for yourself. And as a society, we need to advocate for national policies that ensure that physician well-being, healthcare provider well-being is recognized on a national level and that licensure barriers are eliminated. So back to our first case, the cardiologist, interventional cardiologist who experienced a divorce and is now irritable, angry at work and has impatient behavior, he is experiencing personal grief, a loss in his personal life. For the second case, the interventional cardiologist who performed a complex high-risk PCI and now becomes withdrawn and demonstrates a release in anger after the at-risk patient event, that provider is experiencing second victim syndrome. And thank you so much for listening. Thank you so much, Ketchy. That was fantastic. Very well done. And we will discuss your presentation at the end. All right. Let's move on to Dr. Box's talk then, if that's okay, Lyndon. Dr. Box is going to talk about resources for addressing depression and grief, part one. Hey, I'm going to, y'all see my screen there? Yes. Yes. Perfect. So yeah, I'm going to talk really from my own personal experience because this, I think probably how I ended up getting invited to this was after some conversations with Jeff. And part of why I want to do this is to really kind of help with some of the stigma I think we all face. Nothing to disclose. So I'm going to actually begin and this may seem like a self-esteem exercise, but there's a real important reason I'm doing this. I want to brag on myself a little bit. So, you know, I'm about 15 years in and I'm very busy in the high productivity category, at least that's what the administrators tell me. I have a very good track record with low complications, happily married, very involved in my church and my community, three kids who I enjoy, stay pretty healthy, do a lot of cycling. And the reason I'm sharing all that is because I think even some of the comments we got when we were talking about doing this that were on the MySky page insinuates that if you're worried about your self-care that you're whining, which I guarantee I'm not known as a whiner, that you are somehow a slacker, you don't want to work, which is why I was bragging on my productivity numbers because I actually love my job and love to work, that you're somehow dysfunctional at home and that's what the problem is. So really, those things aren't necessarily true and I think that stigma is a lot of what keeps people away, but I do want to share my journey of kind of how I got to this point. And one is really starting out. So when I was in medical school, the state of Alabama felt like it was in the public's best interest for me to quit drinking. So I went through the addiction recovery program there as a medical student in Alabama and there's some funny stories around how that all went down that I can maybe share with you, but regardless, I went through the program, best thing that ever happened in my life, totally saved me from self-destruction and as a result, I've been around these programs for the past 28 years since I quit drinking and the thing about these programs is they really were developed because physicians were dying. People with drug and alcohol problems died because they couldn't get help and they quit working and they got enabled and so they really help save lives and you're protected in these programs and the great news is now they have extended these programs to help with other mental health problems. So people who are suffering from severe depression or other mental illness that's incapacitating them at work, this gives a pathway to get help that doesn't actually destroy your career and you can come out on the other side of it and be way better off than you were before you went in. So I think I just want to put that out there first. If you're in that boat, people view this as oh my gosh, the state board gets involved, it's going to be a death sentence for my career. Actually, the opposite is true. It will save your career and possibly save your life. So I just wanted to share that about those programs are available in pretty much every state and they will protect you and your career. So if you're in that type of situation, the wheels are coming off, you might want to try a reset. Now the other thing that I think my experience fast forward probably five or ten years from that or more, I'd moved from out of academics into private practice and I joined a group and I was there for a couple of years and things were not going well and so I think what they would call a hostile peer review was initiated and there's obviously differences of opinion on both sides but that was a pretty difficult situation so it really made me question, am I in the right field? Am I capable of doing this? And it was totally the relationships through SC&I that helped me. So I reached out to people in SC&I actually through SC&I got connected with an independent peer review of my work and got the feedback that no I was competent, that this was not a competency you know I was within the scope that I could get better but that I was within the scope of competent practice and then a lot of the emotional support with people that really helped me get through that and I think the reason I bring that up is because I had those relationships in place before everything went south and so I really encourage you I mean yes it's important to have relationships with your family, with your friends, with your spouse or with your significant other but it's also important to have those professional relationships because those other people may not understand what you're going through and what you're dealing with and you want to have those in place before things go south so I really encourage you some people are fortunate, they can develop those in their own practice but that's not true for a lot of people. There's a lot of different dynamics in practices and they don't always have that. Sky is a wonderful outlet for that way more so than the other professional societies where you actually can go to a meeting, get to know people, make those networks you know connections and then down the road if things you know if you're in a hard spot you have those people to lean on. Now fast forward a little bit beyond that so I actually made it through the hostile peer review they could not find fault after three months so I was giving my card back so about a month or two after that ended I'd gone I don't know years without a death in the cath lab, had two people die in the same week just both were STEMI patients but you know unusual kind of chain of events totally devastated I'd just come off of this you know whole peer review I mean this this internal review thing and at that point I just was really like my ability to cope was exceeded you know with what had been going on after that so I reached out and you know as they jokingly would say and had a check up from the neck up and got connected with a therapist who specializes in professionals and dealing with people with you know high pressure jobs and those kind of things transformational you know really helped me through something and I was dealing with the second victim syndrome I mean in spades dealing with all the inadequacy that comes around that and it really helped me with dealing with that issue moving forward in a way that allowed for healing and to be healthy and come out on the other side of it actually better it was so valuable so that's been like eight years ago I actually still see the same therapist you know it's now kind of like a high paid life coach that my insurance covers so it's a good deal you know and I block out every Thursday morning at the same time everybody knows I don't do meetings at that time they don't know why they just know that I'm not available at that time every Thursday morning and I start work at 8 30 on Thursdays. And that's been the way it's been since I started. And I don't explain to people what I'm doing. I just am not there on Thursdays till 830. And it's been wonderful. So you know, again, a lot of stigma about reaching out for mental health professionals to give you that support. And I'm telling you, if you need it, don't hesitate, it can really be valuable. You know, today maintenance therapy. Yeah, I mean, resources, things I use, I live in a wonderful area for mountain biking, this is about a quarter mile from my door. So I'd spend a lot of time on the trails. You know, I mentioned the stuff I like with my family with my church, you know, you got to have something outside the cath lab. And that's, that's hard. You know, we can't always do that consistently. But I think it's kind of similar to my therapy, I block out that time. If I don't get enough work done, and that time comes up, you know, as long as nobody's dying, oh, well. So you know, try to try to keep those things in mind that that we need a life besides the cath lab. And you have to be purposeful, like it's not just going to happen. You know, if you're not purposeful about carving that out for yourself. So really, that's just I wanted to share my experiment experience with that. Some of these bigger issues, let you know that, that you're not defective, if you're struggling, and or if you are defective, that's okay. Some of us are others are too. So last thing I'll share with, you know, my hope was was sharing some of that is that maybe there'll be somebody out there that at some point needs to have a shoulder to lean on or wants to get my experience with some of this. There's my cell phone. If you're too timid to call, you can send me an email. But I'm definitely you know, available and happy to talk more in depth and be a resource for you. So, but that's all I got. Thank you. Linden, thank you so much for sharing that story. That is a poignant story and for sharing your contact information as well for basically giving back to other sky members, because you got so much out of being a sky member, it sounds like. So I'm going to go ahead and move on to the next speaker. And then we'll plan to have a little bit of a discussion is going to talk to us about signs, symptoms and consequences of depression and grief. Okay, there's one almost there. Thank you. So my disclosure here is that as I was discussing someone today, I'm not a psychiatrist, I had to go do my own research, but it made for very, very interesting reading. So my objectives are to describe symptoms of depression and grief, review the stages of grief, and really discuss a little about how depression affects one's personal and professional life. I'm sorry, I missed the initial talk by Ketchy because I'm sure there should have been overlap between them. So a few definitions. Depression, we kind of use depression in multiple different ways. We talk about feeling sad or down, anxiety, a feeling of emptiness, discouragement, tearful, even having no feelings at all. That's a mood state. People say I feel a little bit depressed today. But that's just today. And that's their mood. But it's not necessarily a disorder. Then there's a syndrome where it can be seen as a constellation of signs and symptoms, you can have a depressive episode, consistent of all of those symptoms, all or none of those symptoms that we that I spoke about earlier. And it could be a single episode, or it could be multiple episodes. And it's a feature of multiple different psychiatric disorders such as major depressive disorder, bipolar schizophrenia, among others. A psychiatric disorder or major depressive disorder or postmenstrual dysphoric disorder, or depressive syndromes where patients have multiple depressive episodes or depressive episodes can go on for a period of time and that meets specific diagnostic criteria. So, you know, we we approach sometimes the term depression a little bit loosely, but there are specific terminologies. Other definitions include that we need to be aware of when we think of grief and depression, etc. As one, bereavement. Bereavement is simply being the situation in which someone close has died. And grief is therefore the natural response to bereavement. But it can also occur in response to other meaningful, non bereavement losses or like divorce or, you know, you know, sometimes, you know, you've lost something you didn't you didn't get that promotion or you didn't pass that exam or something. So the response to that is still considered grief. There can be prolonged grief. So there's a disorder called a prolonged grief disorder, which is a syndrome marked by these intense symptoms, and it needs to be treated if it's diagnosed. It's actually culturally determined the length of time someone grieves for. So six months is the typical cutoff point if it's going on for longer than 12. That is that is prolonged grief, but that is a culturally determined time period. And then professional grief is grief experienced by professional caregivers after patient deaths. And I'll go into that in a little bit. So the next slide. So symptoms of acute grief can be divided into symptoms of separation distress and trauma or distress reaction. So there's no real single way to grieve and adapt to a loss. The specific pattern of grief symptoms as well as the process of adaptation is kind of unique to each situation. And each individual is influenced again by the culture and cultural mores. So, you know, but we all know that there is these symptoms that can be, you know, easily recognizable. So sadness, loneliness, crying, sometimes shame about not being able to do something about the death or anger when reminded of the loss. There are somatic symptoms such as disrupted appetite or sleep. Even more, more actual symptoms such as or cardiac symptoms, heart palpitations and butterflies and dizziness and all sorts of things that people describe immediately after someone has died. Then there is the signs of the stress reaction that includes things like disbelief and difficulty accepting loss and shock and numbness, impaired concentration or memory. Next slide. So there, I think we all are aware of these Kubler-Ross stages of dying or grief, where we know about denial. So it's a defense mechanism. So Kubler-Ross was a psychiatrist who spoke about these stages of dying. So you're telling a patient that, you know, you have this stage four cancer or you have end stage heart failure or something. And denial is typically the first defense mechanism. And then anger because, you know, surely you can do more for me and you're lying to me. And, you know, the whole world is against me. And then there's the bargaining phase, where they're trying to get some control of measure over their illness. And it's this negotiation phase, you know, I'm going to do everything you tell me otherwise, you know, and I'm going to get back better. Then depression is probably the most recognizable phase of dying or approaching death. And then acceptance finally, is really what you're trying to get your patient towards. So these phases or stages of dying have been taken and, you know, expanded and all grief is, can be kind of fit into this construct. So the person has died, and you are grieving, and then there's denial, anger, etc. The one criticism of the Kubler-Ross model is that, you know, a lot of people try to fit it into a linear model where you're going from denial then to anger, bargaining, but people kind of ping pong between these phases. It's actually led other people to look at other models of grief or to, to develop other models of grief. But they kind of all look the same, the shock and this relief and pain and the depressive type symptoms and maladaptive symptoms finally then adapting to more acceptance and healing and, and like this warden's adapting thing, redirecting emotional energy. So we can take this model of grief, personal grief, and apply it to other models of grief. And then, you know, before I move on, grief, and all these things that we've been talking about, can be seen in people who have PTSD, prolonged grief disorder that I mentioned, and major depression. So let's move on to that. So if grief is not allowed to be, you know, if people don't work through the stages, appropriately, or, you know, come to some measure of acceptance of whatever they're grieving for, be it a bereavement loss or non-bereavement loss, things, it can go on to depression. And, you know, we're all internists, we've all had to, to manage depression in our patients in some form of or fashion. So we know how they present the irritable mood, or in some people who may have bipolar, maybe they're going the other direction to hypomania. But a depressive episode is more the other direction where they're sad, there's loss of pleasure, there is, there can be multiple somatic symptoms, and to the extent that, you know, the fatigue, etc, is evaluated for ischemic heart disease, heart failure, all sorts of cardiac related symptoms. And whereas ultimately, the patient may turn out to have depression. And then of course, we know the things, the sleep disturbances that are associated with it. So this is all looking at it from a personal viewpoint. But then, you know, that's looking at people who've had people close to them that have died. But we as caregivers, we as professionals, working in the healthcare field experience these episodes of bereavement, very often when a patient has died, you know, we still experience some measure of grief. But the problem is professional caregivers are distant mourners. So the effects of professional grief are, are set aside, the effects of that bereavement loss is not seen the same way as if this was a close relative. So, you know, we have to put aside all of these episodes of grief. And sometimes the episodes of grief are not necessarily related to a patient death, it may be related to a bad outcome. You know, like I did a case the other day and dissected the LED and couldn't open it, you know, and that sometimes that keeps replaying in my mind, you know, what could I have done wrong? What did I do wrong? What could I have done better? All of these multiple things that we experience become losses and become interactions in our minds that could become grief, and if not dealt with, could go on to become prolonged grief, and even depression and burnout, like we've discussed before. So, you know, this is my last slide. It's just well, you know, resources are there. So if you can go back to that previous one, just for us to remember that we are mourners are as well when a patient dies when a patient does badly, we still need to approach it from the viewpoint that we may need help, we may need to deal with that loss. We may, we need to understand that these losses accumulate, and they can actually snowball into some of the negative emotions, and the negative coping mechanisms that ultimately need to burn out. So we need to then look at the methods of dealing with that grief, prolonged grief, professional grief, that other speakers will deal with or have already dealt with. So that is it. Thank you so much, Dawn. I think, you know, our jobs are very difficult. Interventional cardiology is a difficult field, and we all have lost patients. I think we've all felt what you're describing there. And we can talk a little bit more, elaborate a little bit on what you talked about in terms of how to manage that. I'm going to go ahead and share my slides. And I will be pretty brief in my talk. All right, can y'all see my slides? Okay, perfect. Yes. All right. So I'm going to just touch on a few resources for addressing depression and grief on my only disclosures are I'm not a mental health provider or professional coach, but I do make life and death decisions every day. And I grieve over the patients that I lose. This is, these are some pictures of some physicians who have committed suicide in the last few years. And I know that we talked a little bit about suicide and suicide prevention. But I think this brings to light the importance of dealing with these emotions as they come up. Because every one of these people did not seek mental help before they took their own lives. And the reason for a lot of people not seeking help for burnout or depression is that, you know, we're doctors, and we think that we should be able to deal with these things ourselves. Why should we need to get help, whether it's physical or emotional. And many people also are worried about having to disclose to the medical board. And maybe Jeff can touch on that a little bit during our discussion. So those are those are the two most common reasons why people don't seek medical health or mental health. We already talked a little bit about second victim syndrome. And so I won't elaborate too much on this, but it is essentially emotional suffering that occurs when you're caring for a patient and that care leads to patient harm. But what do all second victims have in common? So all of us at some point in our careers have or will experience some degree of second victim syndrome, because it involves a deep personal commitment to the safety or welfare of other human beings. And that's basically our jobs every day. And it involves high levels of complexity that are often rapid fire decision making in the face of limited knowledge and significant unknowns, which is many of the patients that come in with STEMIs, and other acute illnesses that we have to deal with on a day to day basis. The symptoms, once again, briefly feeling traumatized by the event, feeling that you're personally responsible, like you've failed your patient. Second, guessing what you're what you're doing, what your career is your knowledge base and skills. And some people start to project their emotions on others. So some of you may have seen people who deal with loss of a patient by trying to blame other people blame the cath lab staff, blame the CCU nurses, blame somebody other than themselves. And that's their way of dealing with it. Now, it's actually kind of startling how many people suffer from this second victim syndrome. And it actually has not been looked at interventional cardiologists. And that's one of the things that we're discussing through the Wellbeing Committee is to find out just how many people at least within SCI have experienced this. And this is actually from Critical Care Medicine from the Society of Critical Care Medicine. And they did a study that showed that 58% of people have experienced this. And if you look on the right side, there's a wide range of recovery times and a small number of people not really small eight to 15% say they actually never recovered from second victim syndrome, which is pretty alarming. So how do you find a support system and we can talk about this a little bit more in our discussion. First of all, I think it's really important. And I mentioned this in a previous webinar that we did last month, that if if you lose a patient, it's very important to allow yourself time to grieve. Because what often happens is, as Don mentioned, is that you're trying to figure out what could I have done differently? What did I do wrong? How can I learn from this? And until you really let yourself grieve the loss of that patient, you're not going to be able to learn anything. And you're not doing yourself any good in the long term, by not grieving that the loss of that patient. Identifying existing connections is basically the foundation of your support network. And whether that's family, you know, so a spouse, a parent, a sibling, whoever you can confide in friends, whether their medical or non medical, or colleagues, you need to have someone that you can reach out to. And it's not always going to be someone in your in your practice, necessarily, you may not have a practice that is feels that supportive where you can reach out to your colleagues. So it's important to establish that foundation before something happens. And you know, local psychiatric consultation is great. But there's also a lot of online consultation. So listed here on the right are, these are all online therapy services that are available. And a lot of these you can actually file through your insurance to to get the counseling that you need. So you do not have to be seen in person. There are actually some websites where you can seek help anonymously. So this is one of them. You can call it in to meetings with other physicians and with coaches, and you do not even have to disclose your name. So there are many ways you can reach out for help. And lastly, I wanted to just provide a few more resources. And again, these will all be posted because this is recorded. So, but if you, if you obviously suicide crisis line is important to remember, but the physician support line is a good resource for people who need emotional support. None of these places is going to provide medications, but can provide counseling that you may need. So keep these in mind. Don't ever feel like you're alone. Prevalence of second victim syndrome, as I mentioned, has not been studied, but probably has a pretty high prevalence because of the nature of what we do. And don't ever be afraid to seek professional help. It's a necessity. You can't take care of patients unless you're taking care of yourself. And I will stop there so we can start our discussion. Let me see if there's any questions in here. All right. So I don't see any questions yet. If anyone has questions you want to type in, please feel free to type in the questions. You can type them to the whole group or just to me. So I'll start by asking the question of our panelists. So I'll ask both Dan and Jeff. You know, one of the things that I think taking care of critical patients in particular that comes up and it just came up today is families that are going through the stage of grief that Dawn was talking about, of denial and particularly anger and projecting that anger on the physician. So you're doing everything you can to help a patient. You're just as disappointed as the family is that they're not doing well. And they're projecting their anger onto you and making you basically feel inadequate. I think we've probably all felt that to some degree. How do you navigate that? In your experience, what is the best way to deal with that? And there's probably no right answer, but I just want to start a conversation. I'll start. You know, first of all, the talks before we start, the talks by the presenters were really fantastic. And I thank everyone, including Lyndon, for sharing personal experiences. It's courageous and it's helpful and it just is a part of community. So I thank everyone for sharing that, Lyndon in particular. I guess in terms of patient families who are in the stages of grief and are angry, I think the first thing is that we try to talk and establish some degree of trust and honesty with the patient's families so they understand that you are also feeling the same way and that you are on the same side. There can be blame and finger pointing and none of that really matters once a loved one has been lost. It's really about just having them understand that you understand their grieving and their loss and you don't try to minimize it. You try to be there for them and hear it. I think a natural tendency would be to sort of run away and not wanna be part of that, but really the opposite of what helps to be present in the moment and let them experience their emotions. And I think you often find that patients' families will then develop some degree of trust and appreciate where you're coming from. So to answer that specific question, I think that's the first approach is to be present, to listen, to let them experience their emotions and to be supportive in that way. Yeah, that's great. And I'd like to echo all the talks were just absolutely spectacular. Jeff, your mic's not working right. Is it working better now? No. Try... No. Just talk really loud. Let me turn it up. There you go. Is that better? I can turn it way up. I have four kids. I know you can talk loud. I would like to say that the talks were absolutely spectacular, okay? And this is a sensitive point. I think that data would show that when something bad happens and this is not the most important point, but like what Dan said is if you withdraw, the patient's and their family's anger actually escalates and can escalate to the point of basically litigation. So I think the first thing to do in this point, in this situation when the family's angry is to take however long it takes in a quiet room with them and let them vent and share your emotions and don't be afraid to show your emotions. Showing that you're human and that you have empathy is probably one of the most important things for the family. Yeah, and what do you think about... Go ahead, go ahead. No, you go ahead, I had another point. Go ahead, Dan. I was just gonna say that one of the related issues to broaden this a little bit is our staff. So Nkechi had several really nice cases from her first talk and one of them was a patient who died during a cath lab procedure and the physician, the operator became very withdrawn and sad and experienced grief and depression and all of the things that we've just been hearing about. And part of this is to, in the moments afterward, to recognize, first of all, it's not just the operator. We have a staff that we work with and so I just would broaden this conversation a little bit as most of us on the call all know that we work so closely with all of our staff members and they're feeling it as well. And so we've developed a policy of trying to debrief very shortly after any event that doesn't go well. And I think that, and there are a number of ways to do it, but it's a very important time and a very important skillset to take care of and to make sure that you're hearing not only from the patient's family, as we just heard from Jeff talk about, but also everyone involved in the care because this second victim syndrome or related concepts extends to us, to our staff, to our nurses and technologists and they are often very affected by it. Sometimes many of our staff members may be young and new to the profession and this is their first experience of loss and they are not only sad for the patient and the family, but perhaps blaming themselves or other staff members for providing inadequate care and you really have to debrief and allow them to vent. Yeah, when you do that in your practice, do you talk about the details of the case or is it more of how's everybody feeling, how's everybody handling this and let everybody kind of share what they're feeling more so than try to go through the nuts and bolts of the case? Yeah, I'll let others comment too. In our case, it's both and sometimes it's at different times I think early on, like literally in the moments after, before the next case gets put on, it's how are you feeling? And then sometimes a day or two later or a couple of days later, it's let's go through the case and see what we can learn from it technically. Yeah, that's great advice. Curious how others approach it. Yeah, that's the same here. I think when you're doing a debriefing with the staff, it's just important to address their emotions at that time and then you can always come back later to talk about the actual technical parts of the case, but as the leader of the group, it's important just to let them see how they're doing emotionally after that event. Yeah, we actually will do two separate formal, not really formal, but two separate distinct debriefs, set everybody down and the first one is what you're talking about, Allison, is an emotional debrief. And when I'm leading that, I try to actually steer the conversation away from the technical aspects, open up with how I feel about what happened, invite people to share how they're feeling at the moment. Also ask the question, does anybody feel like there was something that they weren't heard? I've found that in a lot of times in the chaos, going to the staff thing, that in the chaos of a bad outcome, the staff sometimes feel like they are marginalized or that they could have done something they shouldn't have done, or they should have done something that they couldn't do. And so that's another thing is just, is there unfinished business that they have emotionally that they want to get out? And then there's the debrief of, yeah, the nuts and bolts of the M&M, trying to figure out what happened to prevent it in the future, which for me, I feel like it needs to be a separate process almost, because the two together is a mess. Any other comments on that, Don? No, okay. Do you have any questions? Because I don't want to ask all the questions if you all have questions as well. I had a question for Jeff. Sorry, because I know you talked about this with the recovery programs, realizing it varies from state to state, but I know you've been very involved in Georgia, because a lot of confusion I think people have around if I enter into a program for drug and alcohol, or if I enter into a program for severe mental health, my license will be revoked. I'll be, my career will be ended. There's a lot of that fear that keeps people out. So I know you've been pretty knowledgeable. I was wondering if you could speak to that. Yeah, is this better? Can you hear me? Yeah, much better. Okay, so yeah, I've been on the Georgia Composite Medical Board for way over a decade. And every state in the union has something that has a name like the Physician's Health Program or Physician's Health Program. And those are established and actually adjudicated by a large group of members of that across the country under the umbrella of the Federation of the Society of Medical Boards. So all of our state medical boards belong to the Federation of State Medical Boards. And a cousin of that is this Federation of Physician Health Programs. And every state has a very similar law that if you self-report or somebody reports you for anything, alcohol, drugs, severe depression, suicidal ideation, immediately you are taken out from underneath the investigative process of the state medical boards. Their primary job is to protect the public. And so as long as you're in one of these PHPs, then the public is protected. And by law, the physician is then protected from any kind of investigation or any kind of punishment. And everybody should know that. So nobody should be afraid to do that. And when that is completed, every state has different rules about how long people stay in for different kind of illnesses. But when that's over, it's just admonished. There's no then, unless you've done something with bad care or broken the Medical Practice Act in some other way, it just kind of evaporates. And so everyone is protected and nobody should ever be afraid to call the PHP. You can get on your, you can Google in each state, how do I contact the Physician's Health Program in Georgia? And bingo, it'll come right up and you can do it. So don't be afraid to ask for help. You're very, very well protected. And those, the conditions that fall under it, is it like a certain severity of condition or any? No, it's anything where you feel like you're impaired. Okay. So if you feel like, you know, you're drinking too much or God forbid, you get arrested with a DUI. After you talk to your lawyer, the next call should be to the PHP because we have a tremendous, we're all under tremendous stress. And there's a huge, all of you know, huge physician shortage, especially in cardiology. And it behooves the state to keep doctors healthy. And one of the most important things to know about this is recidivism amongst doctors with drug abuse, alcohol abuse, depression, et cetera, is unbelievably low, incredibly low. In the state of Georgia, I was at the State Board today and we had a report from the PHP. Recidivism for alcoholism in the state of Georgia is like 8%. The national average is 60% for non-physicians. So it's, people with these illnesses are treatable just like people that get AML or people that have an MI. And that's recognized by every state board across the union. Thank you so much, Jeff. Yeah, I think it's important for us to remember that we're all humans, we're not super humans. And we all, you know, there are many, many of us that are gonna have some sort of either emotional struggle, addiction, substance abuse, something. And it's good to know that we can reach out for help and get that and not be risking losing our license in the long run. I had one other question. I know we only have a couple of minutes left, but I wanted to ask Lyndon, because I think there's probably some people out there who heard your story and thank you again for sharing it and think to themselves, I don't have any kind of support network. If that was me, I don't know what I would do. So looking back, how would you say that someone should start to get that support network if they're already in the state of mind where they are in need of help urgently? Yeah, I think if you're already in the position in need of help, you know, one is just doing a trip through memory lane of the people that, and I'm basically referring to professionals within the field of cardiology, you know, I think we can reach out for mental health professionals. I strongly encourage that, but also colleague support. You know, I had colleagues that I reached out to that I knew from training, you know, and that was one that was extremely valuable. And then, you know, the other thing was just knowing the people within SC&I that I'd met that were, I, you know, kind of thought, well, they're a nice person and approachable. You know, we're all in the business of helping people and we like to help people. So I think that, you know, when the things, you know, having those at least acquaintances, even if they're not deep friends that you can reach out to and realize that, you know, I think part of why I wanted to share my story too was that, you know, I feel pretty confident that most people are not judging me as a screw up. And the reality is, you know, if you're struggling and you reach out for help, they're gonna wanna help you. They're not gonna review you as a screw up. So it doesn't have to actually be, you know, a close friend. It just needs to be somebody that you reach out to and then give them the chance to help you. And I think you'd be surprised that most people are gonna reach back with a helping hand. And so that would be, you know, overcoming, my advice would be overcoming that fear and realize that, you know, most people are gonna wanna help you and be okay with the fact that you need that help. That is fantastic advice. And I think, Alison, that also embraces what Lyndon said about, you know, community and SC&I, right? Because we're all working together towards the same goals. And so having people, SC&I members realize that SC&I is their home, their professional home, and that we're here for every one of us, right? Absolutely, absolutely. There are many mentors in SC&I. And as part of this committee over the last two years, Alison and the others on here, you know, SC&I has been working towards physician, practitioner wellness in so many areas. Mental health, we're emphasizing tonight. We've worked on physical safety, radiation safety, orthopedic safety, and so much more. So I agree with these comments about having a community and having people to reach out to, or as Lyndon pointed out, other communities, whether it's church, local, other organizations, all these kinds of contexts are important, but SC&I is here for you as well. Absolutely. All right, well, I appreciate everyone, speakers and panelists for your participation. Thank you so much. I also want to say thank you to Dr. Hermiller. Herms, thank you for leading the charge on this important initiative during your presidency. Keep the momentum going. Thank you all for joining. And again, this has been recorded and will be available online. Have a great night. Good night. Thank you.

grief

depression

healthcare providers

second victim syndrome

mental well-being

support networks

physician mental health

burnout

trauma