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Fellow uh medical Association members, physician leaders, physicians in training, healthcare partners, faculty and guests. My honor to welcome you to our 2023 education section. The Physician Leadership Workshop, which has been made possible through an educational grant from the Mica Medical Foundation. We're extremely grateful to Mica for their support of physician education, to those who joined us last night for dinner and to those who have served earlier this morning and are continuing to serve in our house of delegates and those who participated in our poster symposium. Thank you so much. We're excited to be here today at the University of Arizona College of Medicine, Phoenix Biomedical Campus to have the opportunity to see the great work being done and the facilities that house the work. And we really are thankful to the entire university and PBC team for letting us use their building today. Everyone joining this workshop. I really thank you for your interest in this very special educational session on a topic for which I'm very passionate about physician leadership. In my tenure as a physician, I've seen the difference between physician, the physician engagement and advocacy and systems improvement can make for our, our patients, our quality of life and our work life balance. And we're thankful to each of our speakers today who are coming in and sharing their time, expertise and experiences before we get started with the agenda. Some housekeeping notes, the uh agenda and other information including how to claim CME credit. Today is available in the program document. You received the registration table. You can also download it electronically using the QR code up on your screen. You'll notice no cards throughout the room. Um I encourage you to use those to jot down any questions you have for any of our speakers as the session goes on. Um Any questions not able to be addressed during an individual speaker's presentation will be able to be discussed in a concluding panel and all of our speakers will be joining us at the front in order to receive CME credit for the sessions, you must sign in for the session today and complete the survey shared in the program document within 30 days of the meeting. We will also send an email at the end of the day. So you can get to that link directly. Uh during our afternoon break, I invite you to visit our exhibit area for networking and to say hello and join Arma and thanking all of our supporters who made this meeting possible. I'm pleased to official pick off our workshop and it is an honor and a privilege to begin our morning with the introduction of Dr ELISA Chapa chair, clinical Practice Committee and Associate Professor of Surgery in the Mayo Clinic College of Medicine and Science. Dr Chapatti brings to this topic, a well rounded perspective on physician leadership since joining Mayo in 2006. She has been a consultant in both the Department of Critical Care and Department of Surgery. Dr Chatel also serves as the chair of, of the Clinical Practice, as well as the co vice chair of the executive operations team in Arizona. Dr Chapatti actually led the hospital incident command for the COVID-19 pandemic for her institution. Her commitment to physician leadership is further demonstrated through her engagement in numerous professional societies and community organizations. She's a fellow in the American College of Chest Surgeons and the American College of Surgeons in our community. Dr Chapel also serves as an ambassador for the ST Luke's Foundation for Haiti, the executive sponsor for the Global Mayo Employee resource Group, and a member of the executive board for the Mayo Clinic Global Health Program as a respected colleague and a dear friend. It is my pleasure to welcome to the podium, Dr ELISA Chatel. Thank you for that awesome introduction. Um Despite all of uh the, the work that I've done, um I um always have stage fright when I get up in front of people. So um it's really an honor to be here and I as a leader. Um You may hear from my talk that it's a continual learning process. And so I'm most excited to hear from my fellow speakers. Um After me, no disclosure, this is the academic thing. No disclosure. No, I don't work for anyone and I haven't invented anything. But I'm, I'm really here today to explain to you why the future of health care leadership really depends on physicians being involved. Everyone benefits from um health from uh the healthcare when providers are involved. So, clinical operations, patients, regulatory issues, quality and safety. Um if we have um physician leadership. And so um Doctor Thompson explained a little bit of why um or who I am, but why am I qualified to give you guys any um advice on leadership? I was really late to the leadership game. And so I trained in a community residency program in Detroit, um and uh trained in general surgery and um ended up getting a critical care fellowship and really enjoyed the team based mentality of taking care of patients. It was really fun. You run in, you take care of patients, you kind of saved the day, loved it. And then um went off to Hawaii um where I began to practice. And then at that time, um I had to really uh use literature to kind of understand what was the right thing to do for patients, right? It didn't have all the answers and started studying a little bit of the clinical research. Ended up getting my master's and phd, not just to get additional titles, but um in the search for truth of caring for patients. And then I uh got my dream job here at, you know, clinic where it is a team based organization where care is delivered um holistically and um met a gentleman by the name of Jeff Mueller who received an award uh yesterday and he really instilled uh in me that um uh we really needed to dig in review, quality review the way we were doing things and provide better care each and every day um to patients. And then I kind of followed in his footsteps. He was kind of the, the guru of operations and caring for people and then ended up getting um additional skills because I didn't have them um and got my MBA. So it wasn't my, my journey um to be in charge of an organization, but it was, and it ended up being my calling. Um So, and then I spend a lot of time um uh doing health care across the world in Honduras and in um in Haiti. And that's kind of my passion. So I'm a clinical physician. II um stopped operating during COVID. Um But I do uh critical care shifts every week and then um during the day, I am an, an administrator and so you can be a clinician and an administrator. They are not, not diametrically opposed. I try to tell that to my husband all the time. When I tell him I support Michigan and Michigan State. He doesn't believe me. But I'm like, you can do these things. Bill doesn't believe it. Um He's AAA Michigan guy. But my goal here today is to tell you why, why I think you should be physician leaders, what skills you need for that. And I think my colleagues will follow behind me and really discuss um in depth more of those skills. But um the point that I'm going to share with you is that those skills don't come naturally, they really take practice and intentional education. And then I'll talk a little bit about some of the resources to get those skills. So here's the, the call to action. Um So we, I'm sure we have some physicians in the room, we have some physicians or some medical students who will be writing that um uh personal statement to get into residency program. And so hopefully yours doesn't look anything like this. Um But really, I want you to think back if you have written one when you wanted to be a psychiatrist, when you want to be that family practice doctor, when you want to be that surgeon. And at that time, you really thought health care was about providing a service to that patient. It was about you and that patient, you were doing everything to learn the pathophysiology and all of the ways of differential diagnoses. So you could connect closer um to that patient and you thought it was just between the, the two of you and then you um get out and you start practicing in medicine and you realize that it's a, it's a lot more than, right. So the clinical care is extremely important. Um But that's only part of your day. There's so much regulatory compliance um out there in healthcare policy, that's ambiguous, really hard to understand. You haven't been prepared for that during medical school and certainly not during your rotations. Um They're there for good reasons. Uh Right, because the government wants to make sure that we have guidelines. So we are concentrated on caring for that patient. But um it can be difficult and then health care government um and those come up with regulations like everyone must have to have an EHR an electronic record and that's a little bit hard when you're out in private practice. How am I going to do this? How am I going to train um folks on uh the E hr and then now there's computer science coming in wearables. Um And then the other one is you go out and practice and many of you have gone in private practice and you are trying to manage operations, hr um uh delivery of uh supplies to your patients and then the requirements for continuous quality improvement. So makes sense. But you're also part of gathering all of that information, reviewing it again in that search for truth and ensuring that the patient, not the patient just before you, but the future patients are going to receive um good care. And then you also thought during medical school and residency that you would be there to educate your patients and educate your their families. But it's really important for physician leaders to educate everyone. You have to be a health care advocate to ensure that the broader population is cared for in a better manner. And we have to talk a little about, about, about revenue um and reimbursement. And so it's not as simple as doing a service and getting paid for it. And we know that uh currently there's an erosion in how uh physicians, nurse practitioners, physician assistants, C RNA S. Everyone in the healthcare industry is getting paid and you don't go into this field because of payment models. But you as a physician have to be part of that, that discussion. So you can do preauthorization. So your patient doesn't have to pay for it so your patient can get those medications. And so these are really important skills that you don't necessarily learn in medical school because the, the fact of the matter is and all of your friends who didn't go to medical school. Understand this, the ones that went into business healthcare is a business. It's a $4.3 trillion business and it continues to grow. It's 18 something percent of our um GDP and so a business takes more than just an interaction um between um our patients. And so it is really important for us to understand the elements of business. So what's happened over um time and you can see it's even more prominent um during uh COVID, we've seen a lot of the physicians out there and it doesn't matter which specialty, there's so many physicians who are now moving to an employed model, um for a variety of reasons because of reimbursement because of all of that additional work that we just don't know how to do. Um, and it can become a little frustrating because other people are making decisions that we're not involved in, um, because it's really difficult to hire staff and keep your own staff. And so, um, uh, we see, um, this exodus to, um, employed physicians in the hospital, I'm an employed physician in the hospital and employed physicians in corporate America. And that's not a bad thing, but it's really important for physicians to be at the table and understand who is writing your paycheck because there is a difference between for profit organizations and nonprofit organizations. And, uh, again, neither are bad or good and they have their pros and cons, but it's important to know if your paycheck is being written by private equity firms, um, capital, venture interest. Um, and, um, we see Amazon Walgreens and all of these folks trying to compete. And so that's ok for the business model. But if the physicians aren't involved in those conversations, then what happens to the care for the patient? And so that's just extremely important. So my goal here today was try to inspire you and tell you why you need to be part of those conversations. Um And what about this is what you guys are doing in the next room. Uh, medicine is really, really regulated. I don't know if there's anything more regulated, maybe the coal industry, the airline industry, um uh outside of medicine. And so we have a lot of legislators and folks who haven't been trained in health care, making decisions and they need physicians as content experts to help them make those decisions. Um Really smart people, poly sci majors, um these types of things. We, I just met a gentleman last night who is a physician who is uh proceeding um down that route, which is just fantastic, but again, he's a leader and he is taking additional time as a practicing physician um to uh represent us. So this is a slide that has been um seen in multiple, multiple venues. And so it's a little bit of an exaggeration, but it supports my position. And so I'm making you guys look at it. So this was a slide that looked at the percentage of jobs um in America for physicians versus healthcare administrators from 1970 to about uh 2010. And what you can see is that the number of physicians grew by 100 and 50% during that time period. However, there were so many more administrators that grew 3000%. Um And so who's making decisions for us in the health care field? So, it's my point today to tell you that it's your calling. You need to be a part of um all of those things in health care to make sure that we continue to keep the patient at the center of all of our health care decisions. And so, um, it, it's um important for us, um, to think and ask ourselves a question since I've said that physicians should be at the table. If physicians are at the table, do we do a better job than all of those administrators? So I um come from an organization now, lucky I've had multiple other organizations that I've worked at that has a physician leadership model. So Mayo Clinic is one of those uh organizations that started like many other organizations in the 18 hundreds where a physician started, you had a wealthy donor and there was a religious body, um dedicated to service the sisters of Saint Francis, um who helped start a hospital. And that's a common story across the United States. And back in, I think it was 1935 you would probably see about 40 or so physicians that were running hospitals in America and it's down to about 5% now. Um So does that mean that um physicians are better leaders of hospitals or are administrators better leaders of hospitals? Well, this is the um US news and world report ranking from last year of the top 20 hospitals um in the United States, one ranking system. Um obviously they use some uh objective data, um some quality scores, some patient experience scores, there's some subjective data as well in their reputation scores from other physicians. But it is one of the uh scoring systems that exist out there that help direct consumers to hospitals and in the, the top 20 hospitals. Um and I, you know, I had to bold my hospital there cause we're a little tiny uh hospital less than uh 400 beds compared to some of these big guys. And so I'm super proud of it. But if you look at the number of physician leaders that are running the top 20 hospitals in the United States, there are about 13 of them. And then I, I'd like to note while you're um looking at this slide and I'll talk about it a little bit later. How many have dual degrees? There's only about five of those um physicians um because that's a question that I always get asked. So again, that was just one ranking system, right? Um And um obviously, um that doesn't mean that that's the truth. But other individuals had looked at whether or not having a physician as a CEO um means that your hospital, your organization will provide better quality for patients. And then also again, we talked about how um being a physician is a business. Um do you do better from a financial perspective um as well? And an efficiency perspective. And so this was a study done um looking at Becker's um as well as the Medicare database. And it looked at the top 100 and 15 hospitals by size and compared those um hospitals. So there were only 34 that had physician leaders compared to a manager. So, um, MHA A um MBA um and evaluated um in the specialties, were there better outcomes in the physician L hospitals? And it did show that there were better outcomes in the physician L hospitals. There was no difference in revenue. Um The physician hospitals didn't make more money, didn't make less money, there was no difference. And then another hospital again, you know, this isn't high science at all. Um But um, um uh essentially observational type of study, empirical evidence. And this looked at um uh another database of physicians and specifically, they pulled out that physician lead le led hospitals had a lower in-house mortality for pneumonia and they had higher patient satisfaction scores when you had physician leadership in this study though, it showed that um, physician l hospitals uh actually had less of a financial per performance. And why would this be, you know, obviously, um because it's my lecture and I get to speculate, I do believe that perhaps in physician like organization, we have better connections with our staff members. And so we may perhaps be able to have a better trust um on the floor, especially in physician hospitals that have practicing physicians that are out there on the floor. Um We look at things a little bit differently than administrators. Um And so, um obviously all empirical evidence, um but it is something that I believe in. So, of course, I had to find additional literature to support this and um it's out there. Um Amanda Good Goodall um has written about expert leadership, it's called the theory of expert leadership. And she studied initially in um university residence um and uh versus uh university presidents that were scientists, P hds that had worked and done research within the university over um uh traditional MBA business type managers. And she also looked at uh basketball coaches that were previous coach, um uh players and in um physician uh leaders as well to evaluate um uh and support this theory of expert leadership. And what she's found is that those organizations that do better and those teams that do better if the leaders have technical knowledge of the core business. So they're entrenched in the core business and it kind of makes sense, right? They know things at a different level um than perhaps some of those administrators because they haven't worked on boots. Uh uh haven't been boots on the ground and they've walked the walk, walk, the talk. He said yesterday, they've walked the walk and so they understand it doesn't mean that those management skills and leadership skills. And we'll hear about those today because you need those as well. Um It doesn't mean that those aren't necessary, but this is a huge part of running an elite organization knowing intimately what's going on in that organization. And in addition, the longer you're in that organization, the more experience you have leads to expert leadership. So, um hopefully, um I've made the case um for you being involved and continuing um on this path or um starting on this path for uh physician leadership. But now I wanna talk to you a little bit about why I believe that you should train. So we do not have those inherent skills um from medical school. Some of you are born with those um some who have spent additional time. And I know there are many people who are doing additional work, getting master's in science of healthcare delivery and um spending additional year or two, working in offices, working in um uh the government and learning those skills. But most of us in medical skill, um medical school have not learned leadership skills. However, if you ask a bunch of surgeons and I get to pick on surgeons and I got this from one of my um my colleagues at work and he was giving a lecture on why surgeons are natural leaders. So if you look at um this, um it really tells you about managing teams and so you start managing teams right away when you are a resident, right? So you're a resident and they're like, these are the medical students that you are in charge of. Now, these are the things that you have to get done during the day and then you move up and then you're an attending and they're like, all of these people are um you're responsible for and that's really little leadership, right? That's positional leadership. Um uh it's leading by doing so people can get things done. This is management. Um It's not really leadership. There is a big difference between leadership and it's not our fault. We're taught this right from the very beginning, you go through undergrad, you're competing with everyone else on your individual scores and then you're in medical school and you're competing with everybody else on your individual scores and they're getting away with, away from those scores. But still they're looking at your other skills and you're still being um uh put in a, a position where you're competing and then there's a hierarchy that exists in medicine. There, there's some of that old school um thought process um regarding um someone's in charge and you have to listen to it and sometimes that really important, especially in times of a crisis, there has to be somebody in charge in order um, uh, to get things done and make things safe. But we're really not taught how to lead, how to motivate others, how to align others. But we are really taught how to do and there's many people and myself, you know, I went in a trauma surgery because I would come in and I'd say the D day and I'd be like, it's obviously because of your spleen and I'll take out your spleen And I'm like, thank you very much. I take out your spleen. And so I'm honestly the coolest person you guys help me. So send you a pizza, but it, it's not leadership. We don't get awards in medicine typically for um teamwork, um which is really, really different when I got my MBA because when I went to um business school, every single class, we got um uh set up with a team. So there were four of us and so we had to accomplish everything. So if it was finance, it was finance teams, it was um accounting, it was accounting teams and we all succeeded or failed um in a different uh uh depending on that team. And so everyone knows, people bring different skills uh to the table, but this is how business is done. And so it, it's really um important to obtain the skills, reset your mind frame from your M DDO training and um evaluate um how you're gonna move forward as a leader. And again, this is a little bit more and why um uh physicians may not make the best leaders, great managers, but maybe not the best leader. We get really frustrated um with the business model, we don't understand it. It happens all the time. You hear people, you start giving them feedback, you have an administrator come in and they're like uh the pencil pushers are here. I just don't want, they don't understand. I wish they would just leave me alone so I could take care of that patient. Um And I do it myself, that demonization of managers sometimes, you know, and I'll see my friend um Bill and I'll be like, oh what are you doing next week? I'm a clipboard doctor. I'm just walking around with a clipboard, but it's really important work because I'm there to help the patients get better utilizing the whole system and also representing my other physicians. And so this type of thought process has to be unlearned. And so, II do believe my other colleagues will talk a little bit about the difference between being a manager and being a leader because it's really important to reset your mind frame, talk about it a little bit more. And um I'll say um because I have it here, management is focused on processes, systems plans and schedules to ensure that work is conducted effectively, right? So you have some ob object objectives that are achieved. Leadership is a little bit more about strategic direction. Motivating others. There's a concern for wellbeing which is really, really important um when you're leading um uh people. And so to quote another author, leadership changes, culture, it creates and changes cultures where management operates within an existing culture, both you need both to be a successful physician leader. But it's important to be intentional and learn and develop the skills in each of those. So if anything, this is the uh uh in the next slide, these are the next two slides. So this again and a lot of my paperwork um or my, my um my papers are from a physician, um surgeon, surgical leadership, but um they're very applicable um as you move on the continuum and this actually is really good for people who are outside of medicine as well. Moving into leadership, as you move from the continuum of taking care of professional and individual goals where you have a large amount of technical skills and technical knowledge as you begin to move into leadership, you do have to ma learn, get those management skills to learn how to get things done. But the personal leadership skills are just extremely important and people like to talk about them as the soft skills. But those are the things that make are the difference between just being a leader and being an expert leader. So this is a slide that I want you to um remember being a clinician, being an individual practitioner, whether or not it's a physician, um a nurse practitioner, um a physician assistant, someone in health care initially is about that those clinical skills, learning how to care for a patient and you still need those relationship skills, those relationships, relational skills are extremely important. But as you move up on that continuum into leadership, those relational skills become more and more and more and more important. And then if you are going to move forward and become a leader, you have to gain those business skills. So some people gain that during their uh very few gain that during um their residency training and other people get it um when they're starting the practice from their private practices or from um their, their organizations, if you're lucky to have an intramural program within your organization to teach you that, but you need to know how to read PNL statements, you need to know how to balance um books, look at accounting, get it, get supplies um to take care of your patients. But then you also need strategic skills and strategic skills are about looking towards the future and making decisions. So you can get your patients on the best path, best path forward. You can get the organization on the best path forward. And in many ways, those are the hardest decision strategy. So back here when you're being a clinician, some of the dis the the decisions, you know those differential diagnoses and the way you think are really there's a right decision and the wrong decision. You're gonna come to a diagnosis. This patient has a ruptured spleen or it doesn't have a ruptured spleen. It's diabetes or it's not diabetes. There's a, that, that is, um, it may take you some time to get there, but there's a right and a wrong decision as you move up in leadership. It's about an, um, sister tyranny that I work with. Um, up in Rochester says it's about the decision between two rights, two goods. That's really, really hard strategic decision making going, you could go in this direction and this could happen, which could be good or you can go in this direction and this could happen and it could be good. But what are all of those other factors involved? And that's a little bit hard, especially as you try to negotiate and get people on board. And that is part of obtaining those skills for leadership. And it's kind of fun um especially um as you start to learn them, but when you first start practicing them, it's a little bit clunky, it's a little bit difficult. Um And we have a lot of uncertainty and so, um again, power and influence leaders, influence others and motivate others um to perform better. And there is this um book by John Maxwell regarding the five maximum levels of leadership. And so the positional leader, this continues to reinforce what I was talking about. Positional leader starts even right when you graduate from medical school and you're a doctor, obviously not a doctor of nothing but you have that position and people are looking to you for answers and they have to follow you because you put that order in as you move up, people start to get to know you. And especially with those relational skills, they begin to follow you because they want to, they think that's a great thing to do because you are a good person, you have good intentions, you care about them. And then as you start moving forward, you have those skills and then you're actually making some good decisions. So you're getting things done. And so there are people who will follow you because they're like Michigan is winning. So I have to support Michigan. So they're doing something good. But the pinnacle is when you are developing other people, you're taking people into their fold, you're empowering other people, you're doing the right things people are following you, but you're spreading that leadership. And then I guess there's 1/5 and that takes um time and people leaders who are deeply embedded in leadership, I think I'm somewhere between the, the two and the three, my colleagues will talk a little bit more about leadership skill development. Um But I did wanna talk about some of the, the critical leadership skills that are um just extremely important um in that relational um aspect, these are um skills that I've actually ob obtained, um, through specific courses. I've, I've sat through a whole entire negotiation course, really difficult, really important communication course, having a coach, coaching others, actively practicing, coaching others. Um, my day to day job is crisis management. I spent two years doing COVID crisis management. One of the hardest things that I ever did, but probably one of the more hard things that I'm doing, which I just did yesterday was sitting with one of the orthopedic surgeons and sitting with the department of surgery chair and resolving conflict. Very, very difficult thing to do to get folks aligned in the same direction. I have a partner at work. He's one of the pulmonologists and um he was one of my mentors that I'll show you later and he would say what's a medicines doctor favorite sport, watching two surgeons argue, he's like, have fun. And so getting, walking out of a room after you have brought two people together who had very, very different opinions and getting them aligned moving forward because um uh it's about that patient. That's the easiest thing. It's about that patient and doing the right thing for the patient. And then understanding that both of them wanna do the right thing is just uh an extremely important skill um to learn. And so I would implore you to um really spend time on that. And as I um continuing my leadership journey, this is the thing that I um probably am plagued by mostly. And that's, I like to talk. I like to talk a lot. I don't like to talk in front of people, but I talk all the time. And so I need to learn to listen to people better. Right. So Jeff Mueller, um, again, uh one of my mentors when he gave me the job of, uh, now you're the uh chief medical officer of the hospital and I have a piece of paper and he gave me one piece of paper and he was like, these are your duties on this piece of paper in bullet form, half a paper. And he said you are going to be stopped in the hallway all the time and people are going to unload on you, they're gonna unload their problems, right? Try not to solve them immediately in the hallway. He's like, I know that's your initial instinct. You want to start ta talking to them and say why and follow up on things and then sit down and um ha and put a meeting together. He's like, people want you to listen to them. A lot of these problems are gonna be solved on their own and you can solve them later after they've had time to think and you've had time to think. But listen as a leader, you really, really need to listen. Sometimes I have to give myself pep talks when I walk in a meeting. I'm like, ok, I'm running a meeting. I make sure that I don't talk, don't try to fill in that silence and let other people talk and that will make you a better leader. So then the business skills, just one slide on the business skills. Do physicians have business skills? Some of us do. But again, this was a study. Um, and, and you know, surgeons who we think we know pretty much everything. Um We asked um a group of business and not me. Um this physician asked a group of surgeons, there were 100 and 33 surgeons and asked them um to rate on a lier scale from 0 to 2. Again, most like your scales are um 0 to 5, but surgeons can only fill out one through two. So the maximum number of points um was 232 166 in the points that people get. So if those surgeons, those 133 surgeons all said two, I have um great knowledge uh zero, I don't have knowledge of this skill. Um we could have had 266 but you can see the highest number was, was 1 36 physicians felt they had decision making skills but not even that high um decision making skills um specifically to business, but they felt unprepared from financial skills, risk and return skills, understanding, budgets, high value of money antitrust laws. The these are skills that you have to obtain if you're going to move forward in leadership because you need to be able to talk to people in legislation, you need to talk to people in your um private practices. If you're working for corporate America, you need to be able to u understand the contracts that are coming before you, you need to do these things and understand the economics of health care if you're gonna care for those patients, um that don't. And so this is really part of our charge as a physician. So you're not going to get these skills in um medical school unless they start extending medical school by three years and charging you an additional 180,000. Um But what we are seeing though is that there is a huge growth in MD and MBA programs and this is the most common um question that I get asked because II did spend some time getting an MBA um as I was a practicing physician um doing my clinical work. Um almost lost my husband during that time period. I was like, I'm going to Michigan from Arizona, see you every other week. Um But it was really valuable for me. It was a leadership development program, but this is not for everyone. So then the question again is having it is having an MBA um uh better, does this make me a better leader? And so I have a couple of studies that um looked at um a database and I think there were 3200 people in that database and it was for plastic surgeons. And they looked at all of the leaders who were department chairs, program directors, division chairs and evaluated. Um uh if there was a higher prevalence in um the leaders um who had an MD plus. So it could have been an M PH. It could have been an MBA, a master's in education phd over the other academic surgeon leaders. And there was no difference um in uh the leaders and the prevalence really out of those 3000 people was relatively low. And another study did look at that and it was the same, there was no difference in the, the entire denominator. Um And in fact, only, I think in this 1 13% of the physicians um who were in the community had an a dual degree and 16% of those physicians um in this database had a dual degree who were in the academic field. So really no statistical difference there. But those physicians that did have um uh a dual degree were more likely um to be in um leadership roles. I will say that um I believe that having the dual degree made me better at what I do. But I don't believe that um getting a dual degree is a reason to go into a leadership role because there's multiple um avenues, this being one where you can get those skills and I'll, I'll start with the easiest one. And that's working with those administrators. So even though we had all of those administrators outgrowing physicians, the administrators are not our enemies at all. They're our partners. And we work in a Dyad model um where I work in most uh organizations, I think um have a chief administrative officer, chief, um operations officer, a chief um executive officer that work together. And a, again, this goes back to that team based mentality. And so, um, this is my CEO and my C AO and they're diad uh triad models as well where the chief nursing officer, um, because I'm really a nursing advocate as well, but my partner at work is, um, Sean Glenn and he balances me and he's also a Michigan grad. He, um, uh, tells me, you know, when I, um, am doing something that I think should be just a, just to it from a physician perspective, we should absolutely do this. And he brings me back to earth and says, well, actually from an operational perspective and a financial perspective, perhaps this is the reason why we shouldn't. But now I have the skills to understand that language. I didn't speak the language before. And then when he comes forward and he said, oh, there's this really great technology. If we add another click into the E hr physicians will be able to put in, um, uh, the medications for the patients and then they'll have safer outcomes. And I tell him no, actually, physicians do not go through their day stopping in between patients and adding an additional flick. And so you can learn business skills, you can learn relational skills and some of those strategic skills by having an administrative partner. But I really would like to advocate on um mentorship if you continue to move down this route and if you are in that route, um you know, and again, I started late on that, I had physician leaders that I would just walk in their office and sit down and say I had a, um, a coach that really helped me from a personal perspective, which is really, really important, especially on those relational skills. But I also had strategic coaches where I would come and sit down and say, how would you handle this business situation and met with them absolutely regularly. And I have a ton of coaches and a ton of people that I reach out to, but I had to be very, very intentional, um, uh, reaching out to people not only within my organization who are physicians, but I also, I had a strategic coach coach who was a, um, a former vice president of um Pepsi. So then he could look at the um situation from an entirely different perspective and make me better. And then there's a, there's organizations, national organizations, the American Hospital Association, the American Association for Physician Leadership. And they have an annual meeting that comes here every year, every year here in Arizona. And they have self directed study um uh courses um on uh online and in person. I really kind of like to go in person. And there are, and you'll hear from one of my um uh fellow colleagues today who will talk about his leadership course that he has so outside of the MBA courses where you have to spend 18 months and you know, 100 and $80,000 on top of your student debt um to add on an MBA. There are some uh week, two week long courses out there on the interme uh on the internet, like in Harvard and Wharton that you can sign up for, for leadership development. And those are something that you may want to look into um as well. And I believe that these are in your um they'll come at least in your, I think uh um somewhere I guess I'll just end. I hope because my friend Bill gave me this uh title. I hope that I am um inspiring you and motivating you and um giving you the charge to continue down this uh leadership journey. We absolutely need you and also um um engaging you to obtain these critical skills that will make you better and if you are better and your patients will have a better outcome. And as you think about what is the right timing to do this, I did this when I was a practicing physician and you can do it right at the beginning during medical school. It just depends on, on what your, what your life looks like. At that time, you can do it during residency, you can do it after you're practicing. It doesn't matter. You're, you're never too old, um, never too young to start on this track. And so with that, I will, um, show you this beautiful picture of Doctor Thompson's son who calls me about once a week in the morning and says, hi, Auntie Lisa, what are you grateful for today? I love that child. So thank you very much. What a fantastic talk. Thank you so much, Doctor Chael. Um our second presenter tonight here this afternoon is a fellow Arizona physician leader and won the walk the talk award for 2023. Last night. Doctor Jsle Chadwell, Doctor Chat currently serves as the chief medical officer at Sierra Tucson, a residential behavioral health treatment center in Tucson, Arizona through her various leadership positions. She has demonstrated a history of leading teams through chain. Doctor troll aims to expand the understanding of mental health conditions, trauma, wellbeing and trauma informed leadership while also working to reduce stigma around seeking help in health professionals. She's active in advocating for her physician, for her patients colleagues and community through elected and appointed positions with regional and national medical organizations as well as community based nonprofit associations. During her tenure as the president of the American, the Arizona Psychiatric Society, excuse me, she led a successful effort to change Arizona regulations in order to destigmatize Arizona physicians from questions that we used to have to answer in our licensure regarding seeking care for mental health. Doctor Chadwell, thank you very much for your many contributions. And the podium is yours. Thank you. Um I'm guessing everybody can hear me in the back. So let's get ready to rumble. Um I was asked just last evening why I chose that as my title. Um And I have to admit I used to watch WWE in high school. I for whatever reason, loved it. It was my guilty pleasure in the afternoons when I would get back home from school. So that sort of stuck with me. Um And then there's a psychologist and kind of emotion researcher, leadership researcher Berne Brown. She uses the term run to really show up with your full presence, your authentic self um and have difficult conversations and I feel like leadership is nothing else if about having difficult conversations just like uh Doctor Chappell mentioned. So I appreciate you all having me here today and I will figure out how I move my slides forward and then we will get going there. Ok. Well, um I, I will find the flicker joy. Um I do not have any financial disclosures. I am employed by Well, thank you. Um I am employed by Tucson where I serve as Chief medical Officer as I mentioned earlier, but that is my day job and I will not be mentioning a lot about that here um in a direction. OK. So leadership, which is our topic today. Um And the definition of leadership, as you might see is the art of motivating a group of people to act toward achieving a common goal. So leadership really is kind of a gray zone. It's not something that's got an endpoint. It's not really that we're trying to move in a very specific direction. It's really getting people going in the same direction. Hopefully. So you're not having in an organization in any sort of structure, people pulling in different directions uh and leading to chaos management. On the other hand, is like Doctor Chapp mentioned more about really concrete things that need to be done in organizations and management is the process of planning, organizing, implementing, running the day to day operations of any type of set up. And in my mind, one of the things that stories that comes to me when I think about leadership and management um is when I was in middle school. So I went to a boarding school. Um I grew up in India and we had some disgruntlement in our society. There was a lot of conflict and so my parents sent me to boarding school, go away to the other state. There's not as much political uh issues happening there. So I go to boarding school and they would have eight of us sit around a dining table. So it'd be eight people from different classes. There was, um, middle schoolers as well as students from elementary school. We were in all girls school. We all lived together at this place and, uh, in the boarding school, they would serve us some pretty odd foods like we got boiled pears for dinner. That was our dessert at dinner. Uh, Sometimes we'd get uh some foods that none of us liked. So we were two of us in charge of the table and all of us sort of sat in a hierarchy with the senior students, which was me and one of my cot leads and then the other sitting along the sides and then we had the babies at the end. And so the babies were usually in second or first grade. So really little young Children. And so when it came to us managing that table, we were supposed to bring our food, serve it to each other. Finish what was on the table. You were not allowed extras and you had to finish everything that was on the table. It was nice food. We'd all want to eat it. So the management of the table would go really well. We'd all finish it up. Everybody was happy the table was easy to manage. But then there would be days you'd get the boiled pear that day, we would all look at each other and nobody really wanted to eat it. And so we'd go around and say, OK, you know, we're gonna manage this. We have to finish the food. Otherwise we're not gonna get up from the table. We're not gonna be able to play or have our down time. So we'd start usually by going stoops, stoops, scoop, everybody gets a scoop and then you'd see there was still about a third of the bowl left. And then again, we'd be looking at each other. And so then somebody would say, you know what, I'll take an extra scoop. And so that courageous person would get a scoop and then somebody else would see that person and having had that courage and say, you know what, I'll also take it through. And so sometimes you start to see who the leaders at the table were, who are the ones who are willing to make the hard decision to sort of see how do we get through this dilemma of finishing the boiled pairs. And usually if you were a good table lead and the table leads who were actually like, and their students wanted to stay with them throughout the year were the ones who would themselves take a scoop. And so that's really where I started to learn that leadership can be shown very, very early in life. And it usually is when there's a difficult situation, a person who stands up maybe has the courage to say something that's difficult or take on a responsibility. That's harder. And that's really often how, even in medical school, even in residency training, that's how our residents get identified. Right. They're the people who sort of take on the hard tasks don't really shy away from it. And that's how my own journey in physician leadership started. Um, it was being in a hospital where we needed to manage our units and there was nobody really willing to go to the unit that was having a lot of problems and had a lot of citations during our jo visit. And I said, you know what, I don't mind doing it. There's can't really go lower, it's just gonna get better from here. And so that's how I started getting involved in position leadership and it takes a level of what we call emotional intelligence and what we're trying to hopefully talk about in these next 30 to 40 minutes um that it takes to start identifying situations where you can be a leader and it's not just getting the title and being given a certain position in an organization, but it is the people that folks will just follow or want to follow. And so in terms of emotional intelligence, it is defined as the ability to understand and manage your own emotions, but then also how to recognize um and adjust to emotions and other people around you. So it's really trying to not only sense how do, how am I doing in this situation, but also being able to assess how everybody else around you is doing. And as we know, emotional intelligence is something that's talked about a lot. It, it's a term that got popularized in the 19 nineties by Daniel Goldman who's a psychologist. Um But when in his book, he sort of divides it up into these four major categories. So you see, on one side, there's the recognition and regulation and then on the other side, it's about yourself or the other person. So there's self regulation and self management and there's regu self social awareness, which is about becoming aware of other people around you. But then also social skills and being able to manage how, what you're doing and what you're doing in your behavior, in your actions, how it affects other people and the larger organization. And so what we'll do in terms of these four major areas of self-awareness, self-regulation, social awareness, and then relationship management as we'll break those down a little bit and we'll talk about what are things that you could actually learn as skills um because they all seem vague and it's like, ok, well, it's great to have self-awareness, but how do I do it? And so our hope is that today will identify some steps you can clearly take in a concrete manner and get there. Um One other way of dividing up social, emotional intelligence can be in these five major categories. Um I do prefer the four categorizations because you can break them down further and operationalize it. But even here, it's pretty similar self-awareness, self regulation, having some level of intrinsic motivation, which is you're not just doing things because other people are telling you to, but you yourself are motivated to. And I think all physicians typically have a high level of intrinsic motivation. You don't get through 12 plus years of training without that. Um Then there's empathy, which we'll talk about a little bit in detail and then social skills. So going to those four major categories, um self-awareness as well, we'll start with, which includes emotional self-awareness, having an accurate self assessment of yourself, self confidence and then values, values are again something people talk about a lot and I will often get up and say, you know, my core value is equity and how did I ever get to that? You know, how do you understand what is your value? Um And there are various types of values assessments you can do well, I'll talk about one of those coming up, but it, it is important to start getting clear on what your values are. And as you're in medical school or in residency training, often we do start identify, find what are things that are important to us and helps us decide and define what specialty we'll go into. Then once we're practicing, it helps us assess what type of patient population we wanna work with what type of setting? Um And so starting to develop awareness in those areas is uh fun and kind of interesting. Then social awareness is empathy, organizational awareness service, self management includes self control, transparency, being authentic, adaptable, being able to achieve to a high degree um having initiative and optimism and then relationship management, which is the probably the hardest out of this group uh includes influential um relationships with people, inspiring your teams, being able to work in teamwork. And then what Doctor Chappel was also mentioning around negotiation, conflict management, et cetera. OK. So various books out there for leadership. Which one do you go to? And I would think most of, you know, the books that I'll bring up. So there's seven habits of highly effective people, Steven Covey, it's uh it's sort of an institution upon itself. They have a full group that teaches this model, think again by Adam Grant who's an organizational psychologist. Um dare to lead Bernie Brown. She has a whole gamut of books. Um There's Carol Deck, which is mindset where everybody talks about the hashtag growth mindset. Um authentic leadership start with y by Simon Sick Minds site, the emotionally intelligent leader. And you could go on and on and on. When you pull up on Google leadership books, it's just hundreds of them come up. Um And interestingly, I found that uh having certain names helps. So in terms of emotional intelligence, uh Daniel Goldman is the one that we usually think of. But there were a whole bunch of different Goldman people who had written emotion books on emotional intelligence. And I couldn't quite tell where people decided, you know, I have the same last name. Maybe if I write about it, people might think it's his book, they'll buy it. Um So that was a nice little fun uh tidbit that I found while I was putting this presentation together. Um what we find in all these leadership books is that there is an element of intentionality, there is an element of awareness. So it's sort of deciding, hey, I think I'm going to do something to develop myself or develop my skills. Then there's an element of saying I need to get a better assessment of where I am today. And then finally, there's a third component of deciding to sort of take a step and step into the void, step into the chasm, take the leap of faith, um or live on the edge of discomfort and comfort. Um There's that just that element of doing something that's challenging for you that you haven't done before um facing a challenge in some ways. And so these are sort of the typical elements of most leadership theories in books where you're really trying to get very intentional, becoming more aware and then taking a step that you haven't taken before. Um And those are typically the elements that we find. And so no matter which book or which theory speaks to you, it's about picking it up and getting going because if you start trying to figure out which is the best model, which one should I do? Uh You'll really realize that there's a lot of overlap and it's the same in my profession, Psychiatry. When I came to residency from the U uh from India, I decided I wanted to study psychotherapy and I wanted to go learn all the theories. They are all the different types of psychotherapy. Um And it was really interesting. So I start studying 345 forms of psychotherapy. And in my third year of residency where we do a lot of outpatient in psychiatry, I went to one of my supervisors. I'm like, I'm really confused and she said, why I'm like, you know, I II studied all these different things. There's a lot of theory, there's terminology, but it seems like they all kind of ask you to do the same thing. She's like, yeah, the core principles are the same. And I was like, oh, ok. And so then now when I see people practicing, everybody practices a collectic psychotherapy, which means they mix the different models and do the things that feel right for the patient and feel right for themselves and sort of align into things that they believe in about patient care or psychological development. Um And that's really how it is in leadership. You can really take any model and it can work for you as long as it speaks to you and you can really embody that and work through it. So, emotional awareness, this is now coming to the operational part of the talk. Um Emotional awareness is something that again is a big concept, but really it is a cognitive developmental process. So JP who was a psychologist uh back in the day had uh developed a theory of cognitive development which basically said that Children over the course of their development gradually go through different stages of cognitive development. And what we notice is that emotional awareness is a cognitive skill. It's not something you have it or you don't, it's a skill that can be developed. Um And then the image you see there really talks about the different levels of emotional awareness. One of my mentors, Doctor Richard Lane at the University of Arizona um has worked with colleagues on this model and I've done some work with him. And it's really interesting because if you see that visceral activation, that's what Children have. So this is where Children say, you know, my stomach hurts and usually the stomach hurt is a sign that they're stressed, they're worried, they've got something going on that they're not really able to put a different word on. Then there's action tendencies. This is where Children may act out. They're actually tired or sleepy, but then, you know, they're crying, they're like, why are you crying? You're sleepy, go to sleep. But that's really an action tendency that's acting out your emotion in some ways. Then there's discrete emotions. This is where you can start to say, you know, I feel sad or I feel happy. That's a very broad kind of good emotion, bad emotion uh concept. And as you develop your skill further, you can get into blends of emotion where you can say, OK, well, you know, I'm feeling a little upset because my friend is leaving town. I'm so happy for her because she matched in her first choice residency. And so that's really where you start getting into more complex emotions. Whereas in that discrete emotion, you're saying sad, happy, angry, frustrated and only being able to think that you can experience one emotion and blends of blends is healthy because then you're really being able to say, ok, I feel this way, but I can and I can have the second emotion that's also present. And then when you get into the highest level, which is blends of blends, it's not only for myself, I can say, ok, I'm feeling bad that my friend is leaving town and also excited for her happy, hopeful because she's going to go into her residency of choice. And, and I can say, you know, I think my friend likely feels super elated and happy because she's going to go to the residency. But she may also have some sadness, may feel a little um lonely initially may have feelings of um joy and that sadness mixed together. So I'm not only being able to mental my own experience, but also able to mental the experience of my friend and be able to blend both types of emotions. What we start to notice is that people who are able to do that blends of blends is really where you can get into starting to be a good leader because you're not only thinking about yourself, but you're really able to start to understand how other people may be feeling. Um And that's one of the places where we can develop the skill over time. Uh Not everybody goes through all the stages. I worked with patients who are still in that action tendency space. These are patients who may have, you know, certain personality traits and are not really being able to utilize their words to describe their experiences, but they're really acting out their emotions. So those of you who have seen patients in mental health conditions, sometimes that can happen. Um There's also fo folks who still have somatic symptoms where they come in and they may tell you they have various different somatic complaints, but you do the entire work up and there's nothing. And that's those are people who are still stuck in that visceral activation stage. Um And so between emotional awareness and emotional regulation is another little chasm, emotional awareness is what we're talking about, really becoming aware of your emotions and being able to start to identify emotions in other people. Um emotional regulation. On the other hand, is how you manage that. So if I'm in a leadership meeting and I hear my boss tell me that, you know, they're not really going to approve my project. I may feel really frustrated in the moment. I may know that if I express that frustration by raising my voice or leaving the room, that's not going to be a good look. So some people may use the regulation where they can in the moment kind of hold back, but they may not quite know what to do with it further. And so what we realize in the research is that you need both emotional awareness and emotion regulation to be able to function at your highest. Um And so in emotional awareness, you're really perceiving that emotion, getting a sense of it. But then in regulation, you can do two things. One is you can just suppress in the moment, but that would mean that you might still carry it in you. So it's still in your somatic being, you kind of pushed it down. Um But if you keep on pushing down, there will be a time that those emotions will erupt or they'll start showing up in dysfunctional regulation techniques. So people who may start drinking or using cannabis or we may start to um even go work out and just try and get that out but we're really not cognitively managing that frustration. We're not cognitively managing that negative emotion, the healthier part or the kind of next step could be working towards emotional reappraisal. So this is using that frustration to either inform me about what I could do differently next time and also trying to make sense of it. So that reappraisal means that I'm trying to make some meaning of that negative emotion. So when I'm having that frustration, I can say, OK, well, I feel really frustrated because I my project didn't get approved. It's understandable. I'm upset about this. And what can I do about this? Let me go and make meaning of it that this is a loss, but this is going to make me better. This means I'm going to go research this even better. Next time I'm going to find more collaborators who support my project. I may go start finding my boss sooner and saying, hey, I'm gonna run this project by you, give me your feedback. So that reappraisal really helps in making meaning of something that might be a negative situation. And that can be really, really helpful because as you start training that emotional regulation, you're more likely to be able to achieve higher and be able to sustain the work that you're doing. Because if we're just using suppression as our technique, then we're starting to get to the place where after some time, a box of suppressing is going to get full and like a jack in the box is going to come out in some odd way. Um In psychotherapy, we start talking about, you know, your emotions leak out if you don't start to actively address them. So you can suppress still some time, but typically leaks out at the most inopportune times and in the most inopportune ways. Um So it's not a sustainable model. OK. Um Another technique that leaders can often use and there's a lot of great research around it is reflective thinking or journaling. So you can do reflective thinking just on its own. But there are some great studies that show even 15 minutes of journaling daily can increase a level of self-awareness. Um And all those other positive benefits that you see on the screen, there's increased motivation, um greater resilience ability to be more stable in the face of adversity. Um And so reflective journaling, there's been studies that are done for just 15 minutes a day which, you know, takes a lot of discipline to do 15 minutes every day. Um My husband who's sitting there in the second row is excellent at that type of thing. Um I don't consider myself the most disciplined person on a day to day basis. Um I more so look at like the weekly to monthly type of goals. So that's what I can do. And so again, it's about adjusting what you're doing to your own personality, your own way of operating your job, your role. Um Folks who do reflective journaling, that's just one of those ways that you can start increasing self-awareness. And then also where we're talking about strategic thinking, start to map out some of your ideas, see how that is over time and then every quarter or so, you can go back and look at some of that reflective journaling that you've done and see how you've evolved over time. It's also a great way to have appraisal of your own growth. Uh There's lots of leadership assessments out in the world. Uh The disc is one that's done by a lot of leadership organizations including uh the American Association of Position leadership that I did the disc in for the first time. Um It talks about four major kind of categories which is d is for dominance. I is for influence. I've never understood why it's um not a capitalized letter, but that's just how it is. Uh C is for conscientiousness and s is for steadiness uh in physician personalities. Interestingly, conscientiousness is usually quite high. Um And often as often, we also notice steadiness is fairly moderate to high as well. Uh Dominance is a feature of physician leaders as well. Um So typically the physician leadership style is a CD and then second can be kind of that CS and they take a dot And put it somewhere on that circle based on your assessment. Um And no leadership style is good or bad. It just is what some of these leadership assessments like the disc can show you is give you a better understanding of yourself and it tells you where you are and what may be some strengths of your personality style and what may be some blind spots of your personality style. Interestingly, mine was um a not common type of leadership uh personality because I was ad I and I think in our entire court uh where we did this, there was about 100 people and we were only three of us who were in the D I category and they all looked at us like we were little unicorns and they're like, you know, you guys can go sit at your own table. Uh but apparently, uh the dominance and influence means like you're extremely extroverted, often outgoing, like to be around people. Um A and so, II don't quite understand why there weren't a lot of people with that style, but I guess I am lively and high spirited and all those other things. Um And so that was a fun thing to find. But what I also noticed with that is that, that can mean that I may want to talk more and not be able to listen quite as easily. And so I've had to really try to learn from getting my style to see how can I adjust what is a setting that I'm actually likely to be more successful in than less I'm probably not somebody who would do well in a role where I did not get to, you know, be out and about talking to my colleagues and working with them. Um And so I really had to make sure that I was trying to look at roles and work on things that fit my personality. And I was trying to put myself in a box of um where I wouldn't quite function well. And then another type of leadership assessment is a 3 60 degree evaluation. These are done by various companies across the US. Uh You can find lots of places that do it. Usually what a 3 60 degree evaluation means is that they'll send these evaluations to people who report to you, your peers as well as people who um you report to and then they try to find a mixed blend of people. Sometimes some 3 60 degree assessments are also not only professional, but may also include personal uh though usually 3 60 degree evaluations are done by organizations. And so they might put 3 60 degree evaluations through for a lot of their organizational leaders at different times. And this can be a good way of learning the thing that's the hardest to learn, which is how do other people perceive you? Um Like Doctor Chappell said, you know, most people believe that others see them kind of like we see ourselves. Um And that's not usually true. Folks can see us in many different ways than how we see ourselves some positive and some not as glowing. And so being able to really invite that uh feedback is helpful. Hopefully, we, as we developing as leaders, we can start inviting that feedback without a formal 3 60 as well and be able to create an environment where folks are telling us how they see us and what's going on in terms of our organizational leadership. But this can be a great way uh to at least start getting some feedback. And uh we'll talk a little bit about psychological safety, which is something you need if you're going to do some of these assessments. Um Another one that is pretty common is the Myers Briggs type Syndicator. Um I think when uh my husband Jason and I were chief residents in different programs, different years, we went to a chief resident training together um by the psychiatric association and they did uh the Myers Briggs type indicators for us. Um And I was highly extroverted on that and he was introverted. And then I think four or five years later of us being together, we took the assessment again and we both moved in a little bit closer together, which was very interesting. So again, a way to know that none of these are set in stone like this, your scores can change in the Myers Briggs, your assessment can change a little bit because all of these personality traits are along the continuum and as we're developing and growing and have different experiences, we're always changing. Um So sometimes it's good to periodically take these no matter how self-aware you might think you are just as a way of further expanding the scope of our understanding. Um This is another um assessment, this is for values. So we just said earlier, values are very hard to figure out and understand. Um I've done some exercises where they let you pick a bunch of words on one side of things, you value some verbs of what you like to do and you can kind of create your mission statement, et cetera. That was a very good exercise. And you know, if anybody's interested, reach out to me later. I am happy to send you one of those. Uh But this values index uh that I've taken myself seems to be a very helpful way in an organized fashion to get an understanding around a broad array of value traits that might be helpful to physician leaders or leaders in any capacity. Um When I took this, the one thing that I found about it is that I had a very low economic drive and I was like, no, I like making money. Like I like good things. What do you mean? I have a low economic drive. But what that meant is that I don't have an awareness of the return on investment, which means if somebody tells, hey, Joslyn, can you do this. I'm like, hm, I have time. Sure. Ok, I'll do it for you and so I can take on more projects, say yes to more things in um Then I really might always get value from or it may be that I'm spreading myself too thin. So learning that has made me start to be a little bit more aware to say, ok, what are my values? Where do I wanna go? And so with some intentionality, I can say, OK, maybe I won't take on this project. I really wanna help you, which is sort of like something I like to do. But there's a certain reason that I only have so much time or energy and I have to start knowing that I don't have that economic appreciation. Um So all of those different values again, nothing is good or bad. It's just knowing what your own values are and what drives you. Um interestingly, in this case, political kind of means uh more along the lines of influence, not just having a drive to go be a politician. Uh But the rest of them are pretty understandable as you look at them. Um Now going further. So we've covered a little bit about that self-awareness piece and things that you can do to develop self-awareness. Um And a little bit about self management. Now we'll move into that piece around social awareness. Empathy allows us to understand what someone else is experiencing and reflect that understanding back to people. So what empathy is not is empathy is not saying, oh I know how I would feel in this situation. So now I know how you would feel in that situation. Um That's not empathy, empathy is trying to understand any situation, any uh difficulty through that person's lens. And so having a sense of curiosity, really understanding what that person's value, who's in front of you is and taking that aspect is important. Because if you start just saying, OK, if I was in their position, this is how I would feel, then you're shadowing their experience with your own. And that's not what we wanna do. An empathy has two different elements which uh is cognitive empathy. And so that's really more so trying to understand and taking perspective of that person's understanding and then there's affective empathy, which is sharing the experience of that person. And so when we talk about cognitive empathy, we're really saying, what is your perspective? And how can I really step into your shoes and understand the situation from your viewpoint? And affective empathy is me saying, wow, if I, you know, given your perspective, I understand how you feel. Um So I have a colleague who may want to not take a leadership position, which is the truth. And so I had a really hard time like you're so hardworking, you do so well, why don't you wanna take a leadership position? You say you like the organization, you like the work. But what I really had to understand is that from his perspective, that's not how he saw the role. And from his perspective, he had a different appreciation of the situation. So really being able to attune with him and his experience is what would make me come across as an empathic person. Um One of the things that we can often fall into is sympathy, which is saying, oh for you, I understand how it is for you. Um But what happens with sympathy is we're separating ourselves from the other person. It's saying, oh, that's happening to you. I can see that that's a bad experience for you, but we're not really joining with that person. Um Again, it's kind of a psychotherapeutic concept, which is why I find it interesting, but a lot of empathy is joining with the person seeing the same situation from their eyes and then being able to work through it. Empathy is a skill set so it can be developed over time. It's not something you have to be born with or not. Um compassion. On the other hand, which is very similar to empathy and sometimes gets confused. Um is a daily practice. Compassion is more so trying to work with somebody or a situation to reduce suffering. And empathy is really putting yourself in a person's situation and being able to work with them what we really want as position leaders. And maybe one of the reasons, you know, we all come together and we're trying to do this meeting and work together is that we're trying to develop connection, which is a mix of those two. And so we're really trying to separate them out. Ok. Compassion. This is the daily practice of recognizing and accepting our shared humanity. So this really is one of those things about shared suffering, trying to reduce it. And so we can treat ourselves as well as others with loving kindness. Um And the reason we need compassion as physician leaders, not only for our patients, but then also for each other is that we're often in a consult service in a hospital trying to fight over. Oh gosh, this is such a crappy consult. Why did you give it to me? And one of the ways that you we can really overcome that is having compassion for the team that's referring and saying, wow, you're really in trouble, you're having difficulty with this patient. So let's join together and solve this problem together. It's also in our practice settings, realizing that my colleague who needs to leave early or needs to leave and go at 3 p.m. is not doing that just because they wanna dump work on me. It's because they may have a shared need because of which they're doing that. And one of the ways to develop compassion is to do loving kindness, meditation. Um It's a fairly simple form of meditation can be done daily. Uh But it really helps invite the experience of other people have compassion for them and an understanding. Um because I'm really guilty of it too, I can really uh start to feel like, oh gosh, these people are dumping work on me. There's so much going on and it's sort of hard to take perspective where in the, when we're in the middle of a busy clinical day. Uh but being able to actively practice compassion um before we get into those situations can be helpful. OK. Um Moving further down the emotional continuum, um there is some research on empathy and healing professions. And so these are some um specific skills that are seen in healing professions that can help with empathy and continue building that feel for ourselves. So there's perspective taking which we spoke about staying out of judgment, recognizing emotion in others, communicating back that emotion. So it's saying I see that you're struggling, I see that you're sad and being able to share with that person and work on it. And then finally, mindfulness, uh mindfulness is not part of the research of Teresa Weissman, who does this research on empathy and healing professions. But mindful is my mindfulness is another component that when you layer it on top of the other aspects of empathy, it really helps us stay more present, stay with and stay in those difficult situations with people. Finally boundaries. Um If you're on tiktok, you see a lot of our boundaries. Uh What boundaries are is something very simple. It talks about what is OK and what is not OK. So, you know, you can tell me that I'm not performing well. However, you cannot be insulting to me, you can give me difficult news or give me feedback that I'm not doing something right? But you cannot raise your voice when you're doing that. And so really getting very clear for ourselves as to what is OK and what's not OK in our work environments and our personal relationships becomes really important. Um There is a social activist, uh researcher apprentice Hemphill and I really like what he says, he says, boundaries are the distance at which I can love you and me simultaneously. So it's not putting one person in front of the other. It's really making sure that there's room for all the people who need to be there. Um And leadership coaching which Doctor Chapa mentioned a lot about. Um I really think leadership coaching can be one of those transformative experiences in which you allow somebody to come in and really follow your leadership journey with you, be able to help you get perspective and understand more about yourself. Um And I think a lot of us who find ourselves in leadership roles sometimes unexpectedly can be benefited by leadership coaching because it is one of those intentional acts that you can do to continue developing yourself. Um And it does take some of those adult learning, intentional change, transformative learning theory into account. And that's a great part. OK. So back at this, and our final part of the presentation is on trauma informed leadership. Part of the reason I wanted to talk about trauma informed leadership um is because that's really the way in which you make room for other people who with you, not only your patients, but also your colleagues um and are able to lead in a way that's really meaningful trauma informed leadership. In the definition is a way of understanding or appreciating that there is an emotional world of experiences rumbling beneath the surface. So what that means in simple length is that all of us come into our work lives, not as just a work persona. We're coming in with our full emotional experience. That means what's happened before in our lives. What's happening currently, if we're having some conflict in the home environment, we may be having a secure parent who's not doing well. And so when we're facing people at work, we're really trying to see them as those whole people who have their own emotions and they're not just fock and robots who are only there to work and do the job. Uh trauma informed care, which is something that's really um becoming popular and thankfully more embedded in healthcare organizations. Um It is a model of care that realizes there's a widespread impact of trauma in our communities, um recognizes that there are signs and symptoms of trauma in all our patients. So not just in mental health, but all our patients come with that experience um respond by fully integrating knowledge about trauma and trauma prevention into policies procedures in the facilities. And then finally, we're trying to resist retraumatisation. I like to talk about trauma informed care because trauma informed care is not just for the patients. Trauma informed care is for our nurses, our health techs, our fellow physicians, we really want to know that everybody in the healthcare organization is coming with this full breadth of experiences. And hence, we want to be more trauma informed in our settings. There's four principles of trauma informed leadership that are usually touted. So there's general trauma informed principles um that's in leadership and care, et cetera, there's adaptive leadership skills for managing change and those are the ones we'll spend a little bit of time on, then there's fostering supportive environments and then finally, implementation strategies for organizational change. So more at an organization level, these are put together by the National Council of Behavioral Health. And so they have a really great uh toolkit also on how to put trauma informed care and how to really embody trauma informed leadership. So the principles of trauma informed care and the general trauma informed principles are in front of you. They include safety, trustworthiness, transparency, being able to provide pure support and mutually help each other, collaboration, empowerment, voice choice. And then acknowledging that there's cultural historical gender based trauma uh and experiencing that people are coming in with, then there's adaptive leadership skills for managing change. These are really the big pieces about where we can develop our skills. So advocacy, advocacy is really lending your voice to a cause coming in with thoughts about how you want to change a situation. What you want to do, inquiry on the other hand, is really inviting other voices, being able to understand what people around you need. And so to be a good leader and really to be uh emotionally intelligent leader, we need to have a balance of both um discussion versus dialogue is again coming in with a thought process or inviting dialogue. Um getting on the balcony really means seeing the trees or moving away up top and seeing the forest and seeing the larger challenge in front of us. Um So these are all skills that we can really develop um over a course of time, over a course of practice. And I think the other one I'd wanna talk, speak to that isn't very clear, is stepping into the void. This is really speaking to challenging situations which are not easily understood and may be difficult. So this is really where we're embodying courage in our leadership. And so I think about this uh thing from Aristotle, anyone can become angry that is easy, but to be angry with the right person to the right degree at the right time for the right purpose and in the right way, that is not easy. And that really is the challenge of physician leadership. So when we're talking about working with our business colleagues, really moving physician leadership forward, working with the legislature, no matter where you are as a physician leader, you're really needing to balance that and figure out where you should speak up and where you should collaborate and where really you wanna put your energy uh the fostering supportive environments, this is D ei safety opportunity for collaboration. And then really using those dare to lead leadership principles from Bernie Brown that we spoke briefly about. And the big one that I think is courage, which is rumbling with vulnerability. This is being your full self and showing your authentic voice uh living into our values that we talked about braving trust and learning to rise, braving trust and learning to rise is again, really about speaking to those challenges, being able to stay present in difficult conversations, which can only happen if we really know ourselves, that's the way we can use ourselves as tools to do this. And then finally, the organizational change, this is an organizational structure issue and something that we wanna work within our organizations to lend a voice to. Um And then I'll end with uh my own philosophy on leadership and I call it intentional evolution, which, you know, again, just like every other book it has the same type of um angle to it. In my words, intentional evolution. Um in all the things we can't control. The one thing we get to have control over is how we react to situations that life puts in our path. This ability to choose our own path of change is the epitome of health and healing. So we may not really be able to see what all challenges come in our way. But once we have a challenge in front of us, we get to choose what the next step is. So these are my three steps of intentional evolution, acceptance that change is inevitable. We've seen the healthcare system change over the last 40 years and I hope we'll change some of it a little bit back, at least in terms of regulatory burdens. Um There's thoughtfully choosing how you will approach your leadership journey based on what you're hearing today and then implementing a plan of action that aligns with your values on how you want to embody your leadership. Uh Thank you for attending. Um I wanna also thank my spirit animal. That's my puppy, Tom. Tom who's waiting outside while I'm here. It's a privilege to introduce Doctor Edward Walker. He is a nationally recognized leader in the discussions around physician wellness and leadership development and have this opportunity to participate in a session together in person. Doctor Walker is currently a professor of Psychiatry and Behavioral Sciences and Health Systems and Population Health at the University of Washington in Seattle. He is a nationally recognized for his leadership ex excuse me, his expertise in leadership development and coaching of physicians and other senior health care leaders, improving quality measures and leading change in medical institutions. A seasoned physician exe, executive and clinician. He brings together expertise and clinical systems improvement and clinically informed coaching style that is allowed to him, him to assist physicians and senior executives in their journey of leadership, self-improvement and professional growth. Doctor Walker, thank you for coming all the way from Washington to be with us today. Uh And thank you for your commitment to leadership development and leading change. It's my pleasure to turn the session over to you. Thank you, Bill. But we're gonna be uh presenting some material that you're gonna discuss and I'm gonna try to uh tie together the two phenomenal presentations that we just saw uh from uh Alyssa and uh Gas. And uh I think you'll see uh it's all about burnout and we're gonna try to come to some concrete understandings of what we can do to make uh burnout less of an issue. So my goal is really to do a couple of things, I'd like to build on what my colleagues have already presented it. This is another way of thinking about leadership and we're gonna do it by looking at all of, of course, II don't have any uh financial disclosure to do. We're gonna be looking at a number of things last, last uh shot. If you haven't gotten the audience participation tool, I see two people doing it. So we're gonna talk about three things. The first is I wanna focus on what, what's happening in our country with respect to burnout because our health system is really self destructing at several levels. And I wanna think about um what do you know about burnout and how can you translate what you know into a strategy that makes a difference in your local setting? Secondly, I'm going to try to convince you that the burnout issue is not what we've been told that there's been an evolution of the definition and, and understanding of burnout and it's moved from something that's wrong with us as physicians and residents and medical students. There's something that's wrong with the systems and the systems are actually promoting the burnout and we need to use leadership as a way of leading ourselves out of burnout. So our second group discussion is going to be the delta between where you are now and where you could be with respect to leading your group out of burnout. And then finally building on what we had this morning uh earlier this afternoon with gas and ELISA, what is the, what is the path forward for you? What are you gonna commit to, to make a difference and burn out? So let's, let's first of all remind ourselves what's going on here. Y Murthy is our surgeon general and I was very impressed with this New England journal article that came out uh just about a year ago and he found five attributes of the current system that are markers for its dysfunction. The first is that we're not valuing and protecting our health care workers. Um The, the system has actually moved into a state where becoming a health care worker is actually somewhat unhealthy and unrewarding. And the question is, what are we gonna do about that? Secondly, there's a lot of administrative burdens that have been steadily increasing that make it highly unlikely for us to be able to resolve the issues that our patients are presenting to us. Thirdly, we really lack the mental health awareness of our own uh self care. Fourthly, um our public health system has never been in worse shape. And finally, we have to build a culture that supports wellbeing. Those are design issues about how even a a well functioning normal physician can be overwhelmed by the the issues that are going on in the system. I saw this other thing in the New York Times from Eric Reinhardt a few months later where he talks about the problems even worse than that because not only is the system not designed well to support us, the system is demoralizing us as physicians. And he makes three statements I thought were worth looking at. The first is um what's burning out healthcare workers is less the grueling conditions and more our dwindling faith in the systems for which we were work. So think about when you were in medical school, how altruistic and idealistic you are about the ability to provide care. And yet as we've moved into the system of care that's supposed to be doing that it isn't providing the support that we need. Hospitals are deliberately understaffing themselves, undercutting patient care while sitting on billions of dollars so that the business of medicine and the practice of medicine are at attention that we've rarely seen in the past. And his final statement is our health care institutions as they exist today are part of the problem rather than the solution. So I'm not here to bang on administrators. In fact, I hope I can convince you as uh both Gas and Alyssa have talked about the strongest way to move forward are diadic and triadic partnerships with administrators in a high emotionally intelligent organization where we, we can move forward together. And I'm gonna try to figure out where the issues are, where you can start to do something different on Monday. So when I think about my own career, it's kind of interesting. I uh I graduated from medical school uh in 1984 and I almost immediately got into administration and I noticed every five years my job changed first, it was ensure quality care. Then I moved to make sure it's evidence based as well then it was make sure it's also cost effective. In addition to that, then it was all of that plus safe and population based. Then it was without disparities. Then in 2010, it was all of that, but no burnout for clinicians. And then I retired in 2015 and decided someone else younger than me is gonna have to figure this out. And this is part of the problem. II, don't quibble with this progression. We need this progression. But the question is how do we do it and accomplish all of these things and still have the bandwidth to lead balanced and productive lives. And you all know about burnout, you know, this is uh this is the classic Maslo uh burnout definition and I don't need to read this to you. I think you just need to think about how your days go because a lot of you are exposed to and those of you that are residents and, and uh medical students probably know people who you've had discussions about this when you're a student, school is stressful. When you're a resident, taking on all of these new responsibilities is stressful. But when you finally are put in charge of your own independent practice, that stress turns into a responsibility and the responsibility which if it's not supported externally is what leads to Berna. So my first poll for you is this, I'd like you to, to go to that uh thing and I'd let let's see what the current prevalence of burnout is in the room. If you're a student or a resident and you are not sure you've, you've, uh, you've gotten to this yet, I'd like you to think about some trusted colleague that, you know, really well, and think about what that person has told you what you've observed about that person's life. And if you are a clinician, talk about yourself when I did this type of survey, even 5 to 6 years ago, it was much higher. There were more A's and B's and I'm finding every time I do this talk, it creeps down. It's like an overton window that is gradually changing what's acceptable. How about this? Including yourself? How many people do you know who are seriously considering leaving health care as a career in the near future? You can see the weight is down again on the lower part that we're, we're all experiencing this in some way. How about this? So these are listed burnout causes. This is what when I've talked to people, when I've looked at the research, this is a sampling of the types of things that we see. And I want you to start doing a mental sorting. Some of these things have to do with choices that I make or that you make personally and some of them have to do with choices that the health system, the way it's been designed has been set up and, and start this sorting process in your mind because this is a multifactor problem. And when we think about how to assign that some of the things are clearly things where we bring our own pathology to the, to the game. So these are the types of things when I've done coaching of physicians, both leaders and, and as a psychiatrist dealing with uh uh people who just wanna talk about stress, the stuff on the left lights up. It's always like lit up because those are the ways in which we self inflict stress on, you know, on our practices. But look at this, this is the new list over here in my mind. This stuff has become more of the issue in the last 5 to 10 years that we're talking about that the system being designed in a way so that it permeates down through the culture of our practices. And we feel all of all of these pressures to, to provide both the care that we were trained to do as physicians, but also to somehow treat the envelope that the care is being presented in and in a sense, one thing that's really changed for me in the last five years is I've gone to thinking about whether or not the burden is really more on us. I mean, our, our liabilities are always gonna be there. We're, we're frail human beings that come into medicine. We do our best. But the problem is um there's something new on the block, which is the system is increasingly withdrawing support. And I think COVID just took this to the next level because what happened was what, what little resource the extra there was in the beginning has largely been spent. You know, you know, the whole story, most of your systems are probably on the edge of financial problems right now or in the middle of it, largely because decisions had to be made about traveling nurses. That was one of the most important changes in the last two years. And as we we we supported agency based traveling nurses, we also missed the opportunity to reward the nurses with better salary and lifestyle from before COVID. And therefore when they had the opportunity to go elsewhere, they did. And one thing I'm gonna give you as a, a little bit of a telltale here is I've learned to listen to when is money leaving the system? Remember in Watergate, it was all about follow the money and when you follow the money in medicine, the question is, is it going to a for profit shareholder? Is it going to a device manufacturer? Is it going to Big Pharma? Is it going someplace that doesn't get to my patient? Now, be careful here because it does take money to run systems. But systems that are able to take every dollar and aim it back towards the provision of health care are in a lot better shape. And when money leaves the system. What we want to make happen is more difficult. So you heard Glen just gave a great talk about uh correcting self management errors that this, this is the thing that we need to do to make ourselves healthy. And Alyssa spent a lot of time down here trying to understand why do as we, why, why do we as physicians have to take up the gauntlet uh of um of leadership because it effect in effect, we can change through leadership, unhealthy workplaces to healthy ones. We can change uh systems where burnout is a normal function of day to day operations and move it away to a healthier culture and we can change the balance between mission and margin. You're always gonna have mission, you're always gonna have margin. The question is, do they, do they work with, say now if there's one thing you come away from in this talk, I'd like you to think about reading this article. How many know about Tate Seld? He's one of the smartest people I've ever met with respect to burnout. And I'd like you to get this article because he has figured the problem out. And I'm gonna show you two articles. One is about the personal qualities of burnout and the second one which I'll get to in a moment is about organizational qualities. So let's look at first I was in medical school in the 19 eighties and I remember the, the attitude that I was imbued with when I left, uh the medical school, did my residency was, you basically have a hard road ahead. And it was this thing over here. It was the idea that there were no limits on work. It was up to me to make everything work out and, and basically, I had to expect an isolated performance based career. And if, if you're a boomer, that's probably the system you worked in. I remember being in the hospital for 48 hours at a time. I remember when I was in uh when I was in uh 1/4 year medical student, I was sitting with a neurosurgical R five at our Harborview County Hospital and it was 4 30 in the morning, we were sitting there and this guy was like the deity perfection person. He had virtually no emotional intelligence that I could detect at 4 30 that morning. He says to me, you know, this is really hard and I felt what I thought was a connection with him. He says this every other night call is driving me crazy. I thought I had a connection with him. And then he says, I'm missing half the good cases and that's what the environment was like back then. And what we did this, this era of distress basically went to this wellbeing 1.0 which was the initial attempt to try to balance the um the, the, the self care and look what we have here, you're not God anymore, you're just a hero and you're focusing on wellness. This is kind of the area that we're in now. This is why we're doing yoga and having these meetings to try to deal, you know, with building our resilience as if there's some like infectious issue here that we have to be vaccinated against. And what Shanafelt is talking about, which I like is, is, you know, we really just have to go back to becoming human beings that have vulnerabilities. We don't want to balance work in life, we want to integrate it. It has to have some kind of coherence for us. And the idea is not just to have a connection where I feel like, hey, we're all in the same, same stewpot together. I wanna form a community where instead of talking about frustration, we're talking about meaning and purpose and the, the physicians that I'm be uh I'm coaching now are beginning to detect the early stages of this as we rethink the way the workplace is, is configured so that our personal issues and needs can be met. Now, look at the organizational side because this is the same three stages, but it's the system. So we didn't know anything about what was going on. We ignored distress. Uh II think it was ultimate ne neglect and physicians and administrators never really interacted. You know, there was basically, you take care of the patients, we'll take care of the building and, and then we got into this idea where somehow the administrators began to have adversarial relationships with us where it was all all about. Well, you know, we're gonna have to focus on the patient's needs and we're gonna, we're gonna treat distress and we're going to blame individuals. And this was all about Externalizing our own distress and being unable because we can't control it but try to figure out a temporary way of dealing with by becoming more resilient, by building an organizational structure that would let us practice that resilience. This is when we were told to do yoga, mindfulness and that kind of stuff. And what Shane Feld says is the real issue is now this is where things are going because we have to have the focus on the needs of people, flexibility, aligned autonomy. And the idea this is the die out again. The idea is that the physicians and the administrators have to be able to work together. So the ideal when you put these two slides together is we take care of our own issues. We we, we mop up after our own personal issues and we take care of ourselves individually. But then we work in a system which has been redesigned around purposeful balancing of the needs of the patients, the needs of the clinician and a system that can do it with, with uh financial integrity. And remember my thing any time you see money leaving the system. It's a missed opportunity. So here's what I want you to do now that you're sitting close to each other. I want you to spend five minutes just thinking about what are the primary factors in your own life? Remember the left side of that dimension, which is, hey, these are my issues. This is, this is the part of burnout that I own because I could be this. But I'm not or I need, I need to start doing this, but I don't seem to be able to and then think about your culture and workplace as well. You know, what's going on there? Do you work in a system that's really supporting you or are there system design features which are pushing the burnout thing in the direction you don't want? And then when I want you to think about an idea about what's the most important thing you could do tomorrow that would change all of this for you. And I've left a little place here where you can actually here. You don't need to use the dashes for the word cloud. You could just write a statement if you have something you wanna tell the group, just go to your phone, write it out. So you're gonna have five minutes to talk about this. Ok. Well, let's move on. Is anybody writing right now? I'll wait. Raise your hand if you want me to wait. Ok. Oh, sorry, let's go back there. Yep. Look at that stuff, all sorts of cooption. It's very interesting. Yep. Yep. Yep. So we can come back to these later, these are terrific uh observations and, but let me for now, let me keep going cause I wanna talk about what you do about this because this is, we've kind of stated what the problem is, but there's a way I think to lead out of this. And the first thing is basically, you, you really have four choices. Um What we used to do is basically yoga, mindfulness and buck up and that's buck up with a bee as you notice. And we want to make sure that we just don't keep doing that because it doesn't really make that much of a difference. You can retire, I can tell you that that works from personal experience, but it doesn't help the healthcare system. Um You can see a therapist that helps too, that helps your side, but it doesn't help your colleagues or you can lead the system out of it. And that's what I'm gonna try to convince you. Now. I want you to think back to everything that Alyssa and Gas told you in the last two hours because I'm not gonna repeat all of it. But I wanna highlight a couple of things that they said that are very important. The first is you don't automatically have the skills to do this. It takes a little bit of mentorship and, and investment in your own leadership. What I, what I call the R two phenomenon is I was always amazed when I was a psychiatry attending on call. I would, I would never get calls from the R twos. They were like machines. They were just admitting people, they had a thing that they needed to do and they went through it with mechanical position. There was never any subtlety in their presentations. It was just either they need to be in the hospital or they don't when the R four S were on call, all of a sudden, everything was nuanced. And the, and the system became much more um refined because they saw all sorts of nuances that the lower level residents didn't see. And so part of what happens is you have to learn the world of administrators. And again, we've, we've seen a little bit of this but, you know, physicians, this is the world of physicians. You know, we, we, this is kind of the way we function. I got a master's in health administration uh in, in 2003. And it opened my eyes because I realized that administrators were worthy partners who had incredible skills that were complementary to what I was learning. And then I started teaching in the MHA program and this is the skill set that I started teaching. And all of a sudden I realized, and these are all all organized left to right. And this is set up as a false dichotomy in a way because I don't think one or the other is the way to go this. These are all continuous. And II think uh Alyssa really set this up really well when she was talking about how she partnered with her colleagues. And what's important is the one of the ways to redesign the system is to befriend the people who are running it, which is largely the administrative group. And when they see you as a worthy colleague, it just gets so much easier. They listen in ways that we never thought they would before. And remember we talked again about how, you know, this is, this is what we most of us experience. I sometimes coach people like and they say, they tell me all of this and just said, you have the nerve to tell me that I'm not a leader. I said, yeah, you're not a leader, you're a manager because what you do is managers do all of this kind of stuff. And if you've ever talked to a lean guru, you know that they are into ultimate standardization and the idea of managing is removing variants, but leaders have a different role. And I want you to think about this. If you were on a cruise ship, the left column contains all of the functions of the cruise ship, the engineers, the people in the in the uh dining area, the telling function, they try to do everything perfectly certain number of RPMs on the engine. They want each of the dinners no matter which course you order, it's gonna come out with the same consistency and the hotel function, everybody gets a little rabbit made out of towels on their bed. When they first enter the cruise ship, it's all the same. It doesn't matter where you go. But the leaders are the people up on the bridge, the captain and his or her crew are saying we need to do, we need to get to a port at a particular time and avoid hazards to navigation and we can't be bound by the weather, we need to work with it. And so what what they do up on the bridge is basically deal with the higher order things. And when you, when you get to be a more senior leader, you start to do that, that journey that, that um Alyssa talk before. I think I have a slide for it here. Um II, I'll just add it here before we get there. This is, this is kind of like the world of being a resident, you know, which is a lot of standardization and this is the world of being ACM, which is a very different type of, of way of thinking about how things should happen. And it's not that we, we don't want to leave the management. You need to know management to be a really good leader. But what, what leaders do is they understand this and then build on the ability to move forward with this additional set of competencies. And so Alyssa's slide was slightly different, but this is the same idea that the relative contributions of the technical stuff that you're doing as a clinician or as a business person and the conceptual stuff shifts. And what I think actually is is misleading in this slide is the interpersonal stuff actually increases. It's not the same through the II borrowed the slide from someone else who I thought got it wrong and really cmos have this ability as again we saw on the prior slide to be able to just kind of think about what has to happen, who needs to do it and what do I need to do to align myself with them in a way that will allow the whole thing to move forward together. The other thing we have to deal with a as in senior leadership. And, and I think uh i it's, it's actually more of a problem with burnout re redesign. Is this whole idea of uh wicked problems. Burnout really is a wicked problem because what you have to do is figure out how to take what's happening in Washington DC, in your state capital, I in your hospital and with all of the different political forces, the economic forces and somehow blend it. And that is a question of va kind of stuff which is volatility, uncertainty, complexity and ambiguity. This is never easy to do. And the flip for va is to change it, to vision, understanding, clarity and agility. And the way you do that is by getting leadership trained as we've talked about before. Most people who are managers who are early in their leadership career focus over here, they see a problem or a threat. It CRE it creates this idea of, I, I'm tasked to fix this and I start to get anxious about it. And so what I do is I have a reaction and what we do is we play single issue whack a mole repetitively, we just keep doing it over and over again. And you get this idea where the effectiveness waxes and weigh ins over time. Whereas what we're really trying to do in leadership is figure out a way to think about what's the vision of where we want to go with this. And instead of reacting to the single case, we're looking at the underlying issues that are more strategic and are more system oriented. And we, we use our passion to form an action that allows for uh energy to be unleashed in the system. One of the simple ways we've seen earlier in the afternoon is by asking questions rather than telling people, we ask them, what do you think we should do? Uh When I go on rounds, uh uh leadership rounds, I look at how much, what's the ratio of telling to ask? What's the ra what's the ratio of first person to se to a second person? So are people saying, hey, I'm the CMO I'm here to tell you what's new in the hospital or are you coming to say, hey, I'm Ed, I'm the CMO. And what I'd like to ask you is how are we doing? And what do you think we should be doing differently? And there's wheeze in those statements and there are statements of, of there are questions that where the leader is saying I can't do this without you, I can do it better with you if you'll help me understand what we need to do together. And you know, we, we basically are focused on these reactive operations because that's the way medical school was. We were actually chosen as premeds to be able to do this really well. You know, the the the whole system is really transactional reactive and acutely uh set up. So what happens is we really train as me to health managers. And when we get quote leadership training, it's really not leadership training, it's advanced management training. We just become really crafty managers. And then what happens is in setting where there's uncertainty and a lack of control. We just double down on that management training and we just do more of it. So the problem is that the system keeps demanding of us this management response, this reaction. But the problem is um that's really not what leaders do. And leaders will do better if they're just allowed to do what they want to do and what they need to do. So it really comes back to this idea. Are we, are we reacting to crises or are we leading change? Here's the crisis management stuff? We, we've talked about a few of these things. And again, you saw again from the two prior presentations, this is what leaders leaders do. And uh II thought one of the most important thing was when Joline told you about this whole idea of adaptive leadership. If you see this, this construct, read about it because I think it is the 21st century way out of burnout and way of transforming the way we think about our organizations. So managers and leaders actually do this in different ways. Just like 9/10 of the iceberg is below the waterline. Managers usually deal with what's in front of everybody. So they're up here. And if you, if you look at these different words that describe how uh the the manager Day is, it's usually about dealing with things and people and kind of situations that are, that are happening that are in plain sight. But just like 9/10 of the iceberg is out of sight. Leaders work at a much more fundamental le level. What they do is if they see the organization as a narrative journey, and what happens over time is the organization is making sense out of the world and is doing that by uh and is doing that by interpreting people's fears by looking at the way uh assumptions are being made. What are the stories in the myth? So uh Alisa, you're, you're, you're in Mayo, what a great story Mayo has and I'm sure it's in the onboarding. You know, when you first come in, you learn about the founding of the organization, my uh medical school at the University of Washington was, was the first medical school in Washington State. And we have a whole story about frontier medicine and, and, and taking a, a former uh territory and civilizing it and, and then setting up a, a five state school for Washington Wyoming, Alaska, Montana and Idaho and trying to put the seeds of a larger system in place and people can get behind that because it has to do with the, with the area under the iceberg. The leaders are able to say there's a big purpose here and you're part of it. And then finally, um the culture change that has to happen is really important. Salary will lure you to a job, but culture makes you wanna stick and no amount of salary will make you stay at a place where the culture is dysfunctional. So senior leaders have to be able to envision what that culture looks like. And then they enable the, the the the midlevel managers and the medical directors to try to make that happen. So if you look at this article by Linzer. It's very interesting because when we, as we come back to burnout, you'll see that the things that made physicians more able to be successful with burnout were things like uh commitment to safety and quality, patient centered care, interdisciplinary teamwork, sense of being valued, diminished level of chaos and control over work. And when you empowered physicians with those attributes, they were much more likely to stay in the saddle and be able to be effective. So before we talk a little bit about this, I wanna show you one more thing because Elissa made a very important point about how education and experience interact. And most people start here. You know, they're an uncertain beginner. They, they don't, they haven't acquired any experience yet and they haven't had any formal training and like many residents who are embarking on their first career nascent um hospital leaders have the same problem that they don't know what they don't know. And, and basically all they can do is rely on that past experience, which is mostly clinical. And this is an area where most people in the early stages aren't as effective as they're eventually gonna be some of them get an academic degree. So some of them go this way and they say, ok, in order to deal with this, I'm gonna basically go get a master's degree in health administration visit, but it doesn't matter to anyone of the m degrees and what happens is because they have no experience. All they do is apply what they learned in school. And it's kind of cute to watch because you can see that it's performative academics and they, they haven't learned the school of hard knocks. And the other group that will start talking with them is here. These are the people that have lots of experience, but they've never bothered to get additional training. So these are the old tried and true, you know, well worn shoes of the organization who are saying well in my day and then you hear the whole thing about how it used to be and their problem I think is everything is reliance on past experience. It's all about tactics. Uh Something worked five years ago, so they'll try it again and, and there's a sense of false confidence and what you really want aspire to is this blend where you are someone who has invested vertically in continuing education, mentorship and coaching at the same time, has acquired experience. And when I coach physicians, I try to figure out which of these two things is the issue right now and it's often one or the other, they either need more training because they don't know what they don't know or they just need to see them in place for a while. And what I have to try to do is help them to be patient with their own development. So what I want, you to do. Now, I, this is conversation number two is what's the delta between what you're currently doing and where you would wanna be if you were gonna lead your group out of this. Tell me a little bit about what that would look like and think about what's the one big thing that you could do Monday? That would, that would actually start that journey for you and when you're ready, put it down here. Go ahead. Five more minutes. Great ideas. Maybe we should start a health system together. We all in the same. Uh All right, I'm gonna move on now. So here's the last pitch I want to have with you, which is how do you turn this into some kind of an action? And I'd like to inspire you to do something local and I'm gonna do that by showing you a little bit about what the challenges are. So I'd like you to look at this, the person to whom I report is an accomplished and effective leader who provides excellent mentorship for me. Are you in a situation where? That's true? What's scary is that this is the motor response so far, right? I know that. See, look at this. This is interesting. Well, you know, there's a rule in hr that uh if you can't change the people, change the people, you know that, that you, you sometimes you have to fire people because they're not, you know, doing the right thing for you. And I think one of the things that, that physicians sometimes end up doing is going to another organization. Remember, salary attracts the culture retains. And I found that a again in my coaching, a lot of the issues that, that I've come about, uh that I've listened to have been resolved by the physicians saying, you know, I'm just really a bad fit for this organization. They go to another one with the same skills and they're stars because they fit the culture. How about this one? I feel like I'm part of a competent leadership system. When we have our Q and A, we can talk about what this means. This is very typical, you know, we're all in very, very different places. How about this? When given responsibility for an outcome, I've given the necessary resources and authority to achieve it. So, what I'm talking about here is someone tells you, you need to be responsible for this. That's one corner of the triangle and the other side is I give you the authority to do it and I'll back you and I'm gonna give you the resources, not just money, just resources to make it happen and you need all three of those to be successful. See, I'll have what she's having. You know, it's, it's, uh that's really where you wanna be on a, on this because you, you have a, a leader who's paying attention that in order to get stuff done you need to be supported in order to do it one more. My organization has a strong commitment to leadership development. A way to operationalize this is whether or not they will pay you to come to a conference like this or they will say, yeah, go get that master's degree because you're a long term investment and we're gonna, we're gonna subsidize that and you see, we're all over the place once again. So what I wanna show you, um, and this is where, uh this is the word cloud. So you either put in one word or if you have two words or three words, put hyphen. So they stay together. What would you describe your current leadership, uh situation as autonomy may be good or it may be bad if you're competent and you're left alone to do the kind of things you need to do. That's a good thing. If you're left just to do the things you need to do because you don't know what you're doing. That's a bad, you know, we're all over the place, right? This is, that's surprising. Oops, I let me go back to that last one. I missed it. I'm the sole proprietor of my practice. Eventually I retire at the moment. I cannot see myself doing anything else. Wow. So what's the way out of this? Well, one of the, I'm gonna give you just a few ideas and, and I'm repeating some things that have been said in this room earlier, you have to have a mentor. If you do nothing else. Monday morning, find someone who you can talk to about this and that mentor should be able to show you, you know where the handholds for moving forward, even things even just starting to read is helpful. You've heard a lot of good books today and I started my leadership journey, not with a uh with a degree, but by just reading books that people told me were helpful. Um attend a leadership wor workshop, you just did that and you are the better for it. Um Attend a course. Now, a course is a more organized set of lectures together that form kind of a coherence. And then sometimes courses can be lumped together into something like a certificate and sometimes the certificate, topics can be linked into AAA degree. I have a master's in health administration. We have an MBA here. You're working on your um your uh what is it? The P CPE this remind me, clinical executive. Thank you from A AAA L. There's lots of ways to do this and I'll bet you what we could talk about this a, you know, after we're done, it's pretty satisfying to learn how to do it. Just like at the end of your ob rotation in third year of medical school, you aren't ready to go out and open up an ob practice, but you delivered a baby. Hopefully, I went to Alaska and I delivered 50 because the people up there were so tired of delivering babies. They a here you do it and you know, sometimes the, the, the doors open up and you get lots of experience. Sometimes it's a drip. But, but allowing yourself to be open to those experience is so important and most most important is make leadership a focus. And again, you heard that loud and clear from Alyssa in her, in her life and, and uh you, you're rising in your career as well. Just so. So I wanna show you what we've done with our Medical Association in Washington. And I'm not saying you should duplicate this, but it might be interesting to set this up and I invite you to do it and I'll be happy to help you. So we have uh we, we, we brought into existence a state uh Washington State leadership development uh uh group and, and basically, it's a, it's a series of courses and ii it was easy for me to build because having spent 40 years in academics, this kind of like rolled off my back. It was so easy. We have a, we have a system of four courses and I want to tell you about each one. So the first thing is we have a 101. Um And, and this is really pretty easy to, to set up the 101 is based on, remember when you were in college? And you had the, the history of the world for, you spent a week on Rome, a week on Greece, a week on Persia, a week on China and it was an inch deep, but it was a mile wide. You got the big picture. And then what we do is we say, you know, some of the things that you learned in this course, I'll tell you, I'll tell you what these are in a moment. Um We, we also do in, in more depth. So for instance, we spend two hours on conflict management as an introduction. And then we have a seminar on conflict management, which is the inch wide and a mile deep. We, we try to really take people into a practice level to see what they can do. And then with this, we, we recognized that the next step that we needed was all of these physicians have partners. So we invite them to bring the partnership. And we, I got the idea for this course from my wife and I went on a marriage encounter for a weekend, which was a structured conversation about the way we loved each other and the way we parented. And we had never had a lot of these conversations because we were lost in the fog of parenting and the fog of being married, which is like the, you know, the fog of war in a way and it, and it, you just don't have the time to say these things and what we do with the Dyad of course is we bring in the uh the medical director of the Family Medicine Clinic and the Family Medicine Clinic manager and we sit them down and we say talk about the following things in a series of graded structured conversations and it works wonders. And then we have this one course, which is my favorite one to do, which puts me at the top of my game. How do you get someone to, to be a CMO or, or, or like a, a division director in a, in an academic medical center? What are the higher level skills that you need? And I, if I don't know if these things mean anything to you, but these are fairly high level um course, of course, components uh like just showed you that big starburst with all the different um you know, uh skills on it. And that, that's, that's from the, the leadership circle. I got certified in how to, how to do that. And I drag my whole group of physicians through that together. They get, they, it's a 3 60 peer review process. It's really cool. Now, one of the things I'd give you as a, a piece of advice if you're gonna go this route and design your own center for leadership development is make it competency based. So people that go through NH and MBA programs often have to deal with a um uh an accreditation that comes by about every 5 to 7 years and you have to have a competency set that drives the accreditation. The accreditation is all about, do the surveyors feel that the faculty have transferred the competency concepts into a curriculum? So this was the NC HL, the National Center for He Healthcare Leadership, which is what drove our MH A and II built our whole system of that, that 101 course around the competence. And what was interesting was one of my more promising students who went on to be a A systems cm uh in a very large national system. As her capstone, she looked at the competency systems. She, she put her whole hospital uh leadership system, the physicians through this, this uh this 101 course. And then she said, what, how do you, how do you think you stand on these competencies? Precourse? And how about after the course and what you're seeing here is there's a little bit of a delta and they're range from left to right in terms of the effect size. So some of the things, you know, physicians are fairly focused on professionalism. I don't think there was much opportunity to improve that. But as you go across here, you see that the distance is getting wider and wider. And when you get to the second group, you see the distance is even more profound. These are ordered in terms of their uh larger level So this is basically the effect size and this is the part where physicians go, you know, this is kind of stuff that I don't really understand in the break and then in the post they go, you know, I know enough about this now that I could have conversation with my cio or my CFO because I at least understand the vocabulary and II can't do a net present value analysis. But if you tell me you're doing it, I can explain it back to you what you just did and why that information is important. So the whole idea of a 101 course, which I hope you'll think about putting together is to do the seeds of, of, of giving people that world history course where you spend a little bit of time on everything so that you, you basically get the lay of the land. So I'm gonna ask you to do one more thing, then I'm gonna stop. So I wanna know what you think, having thought about, not just what I've talked about, but what, what a Alyssa and Gs have has told, told you earlier today. What do you wanna do now and have a five minute talk about? What do you think your next step is? Maybe youve decided to get an MBA, maybe you've decided to build a certificate program or whatever it is. Maybe you're gonna just do something with the American Association of Physician Leader. Doesn't matter. But I want you to think about what's the one big thing that you could do Monday morning that would start you on your next step. You've got five minutes. All right. And Shelby's coming for questions. Anyone have any questions that they've written down or I can always get this, get this started. Um, I think I was, I'd like to start with a question, um, for each of the members of the, of the panel as a whole and then, you know, I know that I have some, some individual questions for each of the speakers that we can do. So hopefully that'll spur in some conversation. Um So I guess for, for all of our esteemed speakers, you know, people who are here are here for a reason, right? They have an interest in leadership and, you know, we have people at various stages of their careers. I think you've hit on it. But if you're gonna give one piece of advice for someone who's a physician in this room that wants to take that step into leadership, you know, and II, you kind of covered at the end, but like what little Pearls have you learned? What one thing would you like to pass along to all of our members here in terms of taking that first step? So any of you can, can begin or anything you wanna say? The, the mazine? Um And we were just talking about this, I think it, it's, it, I think I made the case that you really need to obtain those skills, but we wear a lot of hats, right? So you have your family, your personal life, your clinical work. Um And then um many of us are finding ourselves in leadership positions. Um And so you want to obtain those skills as well. II don't try to obtain them all at once, right? Be intentional about it. Um I uh my husband always tells me you can have anything you want, but you can't have everything you want. At least not at the same time. So just um uh go slowly so you learn the skills um when you need them and practice them, I think intention was the word that was coming to mind for me too. Um So I think definitely considering intentionality in what you're doing in your leadership role. Um I think as a lot of us have said, usually you just find yourself being a passionate clinician or passionate about some specific element of your practice and get sort of pulled into um a leadership role. And I think once you have it or you're considering it taking some time to reflect and really consider, what is it that you hope to achieve through that? Um Because I think if you just go into a system in a leadership role, you do start playing whack a mole. So trying to really be intentional around what is it that you hope to achieve? In that role. Um What is it that you're wanting to do? And I think all the things that we spoke about, you know, that gets you down the path to then develop some level of self-awareness around your values. What are your strengths and such? Um, a and that at least is in my mind the very first step. II was more of an accidental leader that I don't think I ever, at any point in my career decided I want to be a leader. What happened was I was very tactical about it because my first job was on the consult service at the University Medical Center. And I was working for someone who wasn't really interested in developing the standards of the service, how to, how to train the residents, how to make it a service delivery system. And I realized the only way I could give better care was to get his job. I didn't want his job. But I felt in order for me to do what I wanted to do, I needed to get his job. It turns out he didn't want his job either. He was doing it because he had been asked. And so I asked him to step aside and let me do it. He was fine. And, and often the way you do this is you become an apprentice. Like I didn't ask him not to be the director of the service. I said, but I'd be your second in command. And then one day he said to me, you seem to like this. And then I said, actually do. And he said to me, why don't you be the person who does it? And I'll be the second man. And that's an example of accidental advancement. Um So that, that happens more often than you think. So look for opportunities that are based in your passion. I wanna make this better and I find a way to somehow get a little bit more authority and then just systematically keep building on what you're doing. Excellent. Um I have a question from, for, I guess everyone from, from the back and any, any one of you can take this if you'd like, does everyone want or need to be a leader? I can speak to that because in my current organization, I have some people who are amazing physicians and clinicians and are sort of generally liked across the organization and don't really see themselves ever taking a formal leadership role. Um So I think there is the difference between formal leadership and a formal leadership role versus just being a leader. Um I think where the topic of the presentation set is really valuable, where all physicians really in any type of setting are going to be leaders, either of their system, of their service of their unit, uh of the people that they're working with, even if you're in your own private practice, you're the leader of that. Practice. Um So I think being able to differentiate whether you wanna take a formal leadership role versus you're just going to continue, you know, your journey as a physician leader, um which can be a little bit more informal, but you are always trying to bring your team along, getting them to unite around that vision of even doing excellent patient care. Um So it's, it's hard to give up the thing of leadership when you're in a position. It's a, it's a tough question. Um um But I agree, you know, in our profession, it, it's really important for all physicians to have some leadership capabilities and skills. Um And how far you move up in the chain and leadership um I think is uh depends on multiple things. Um Some of it is desire but um other times and II see this often in um uh the underrepresented minorities and women that I lead. Sometimes it takes someone saying I see those leadership skills in you and then you reflect and see those and uh because they're not just um business skills, right? Or technical skills, they're like you are inspiring others, you can make a difference. And so, II think um going back to the mentorship model and um I think you should go around and get the skills and talk to people, right? Um and move forward on leadership based on all of the inputs. But II think sometimes we don't see in ourselves what others. See, I wanna echo those last two points because II see leadership as more of a distributive process. II love the way women lead because they don't think hierarchically, they think in a, in a more horizontal manner and they tend to lead by involving people in relational shared experiences and they don't worry about titles and they don't or they worry less about titles and stuff like that. Now, having said that there are people that you will encounter who decide they wanna be leaders because they crave power. And I saw an interesting study the other day that the more powerful you become uh in the business world, the, the less empathy you seem to have over time that they're inversely proportion. And so, and that's why I like, you know, you talked a lot about Bernie Brown. II just love her stuff. She's uh she's the woman who, who wrote about empathy and lie's presentation. She has this idea that that empathy is a form of leadership where you just connect with people. And I think she would be a great CMO if she were a physician because she would just know how to connect with people and form that distributed layer of leadership where everybody moves forward together. So in unfortunately, in medical school, I think we're exposed to very male oriented, hierarchical command and control types of leadership. And I don't think that's as effective as what women seem to do somewhat naturally. I have just a couple of questions for each of you and then one more question for each of you and then we'll go. So, uh ELISA, in your talk, we talked, you, you went into a lot about dual degrees and we've talked a lot about dual degrees and getting extra training. Um And there was one, there was only one of the studies where I think it was in the plastic surgery literature that talked about, there seemed to be a correlation, those in leadership roles had dual degrees. And the rest did not. Do you think that that is related to the degree itself or more just due to self selection? And it's more of a correlative based upon the position they were in. That's what I think it is. So I think that um those individuals went and because, well, it's all gonna be related to me in my opinion. But I do think that it's those individuals sought out those skills. Um and then um moved uh down the leadership track. So I think that that was the correlation quite possibly they wanted to achieve um department chair. And so they thought that that was important to them. Um Whereas, you know, I found myself in a leadership position and I was like, I don't speak the language here. I have no idea what they're talking about. Um And so then I subsequently got this killed, but I think it's probably the former you um Jas you talked about reflective journaling, which is a really interesting concept. Do you think the value derived from that is maximized by regularly reviewing prior journaling? Or is it more of the process of doing the journaling itself in the research? It shows that just the process of doing the journaling is also effective or is very effective and people can decide to do this reflective journaling simply with um writing out their thoughts and being reflective about their prior day, prior week um or also around a specific incident that was hard. Uh But there's also a whole slew of journals um out there that give you prompt. So for folks who are like, gosh, I don't like to write. So there are some just reflections that can help you get a deeper awareness of yourself. And it, the little bit that was there on reflecting back is really more so gaining an appreciation of where you were before and where you are now and how certain things may repeat for you or how certain uh concepts and thought processes in your leadership journey or your personal life journey even have evolved over time. So it's a good, the the looking back is more appreciation of where I was and where I am now. Uh Whereas the actual practice of doing the reflective journaling had immense benefit that we have noticed. Thank you and then Doctor Walker for those of us who are not yet in leadership and facing burnout, the system's against us. Do you have maybe one or two pearls for how someone who isn't in a position of power can help if not on a system level, on an individual level, I think there's lots of ways one is um being able to kind of talk openly with your colleagues and, and to just share the fact that the system is not working for you and, and you know, ii not a, not the usual way it happens, which is a kind of a, a gripe session where we complain about the system. The question is more, hey, this isn't working for me. How is it working for you? And could we do something together that would make it just a little less edgy for both of us and a little bit more friendly and, and effective for our patients? And you'd be surprised that's a little tiny pebble in, in the lake and it, but it makes a wave and if you keep throwing pebbles in one after the other, that's when the shoreline begins to change. And, and, and the whole idea is creating some type of a mass effect. You know, I, in a way there's a paradox, we, we can't all be leaders, but also everybody is a leader and even followers have a form of leadership. Their, their leadership is to understand that the people who are in positions of designated the leadership, who have the vision who have the training need to be amplified. And I've, I've often watched in institutions like you could have a superb executive team that shouts out the main leadership messages about values for the organization. And every, every time it goes downward level, there's like a 10 decibel decrease in the volume. And when you get down to the clinic and the ward level, it's almost an undetectable whisper. So II thought as I was in middle leadership levels to be an amplifier to try to hold a mirror to the the senior leaders. So I could collect their light and then deflect it around me so that I could make sure that people were being illuminated with the values all and, and being loyal to the really good leaders above me. And if you think about it, that's a leadership function. Great. Thank you. I think that concludes our question and answer question unless there's anyone else who has any pressing thoughts. Um I wanna thank everyone for being here today. I thought that this was an absolutely fantastic session. I know I gained a lot of pearls and I look forward to putting them to work. Uh starting next week when I get home. Um for a matter of housekeeping for CM tonight, you will have to fill out the CM E evaluation will be emailed to you shortly, all of the S talk. So for those of you who are doing the diligent work of the house and are interested in what some of these fantastic speakers had to say all their slides are available um at the UL that's included in there. And as promised, we are on time for our departure. So thank you all so much for participating. And thanks again to our wonderful speakers.