Well-being and Resilience: a Podcast with Jane Thomas, Naomi Saks, Ishwaria Subbiah

Eric 00:09

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, who do we have with us today?

Alex 00:15

We are delighted to welcome Jane deLima Thomas, who was a co-fellow with me back in the day in palliative care. She’s a geriatrician and palliative care doc and is associate chair for professional development in the department of Psychosocial Oncology and Palliative Care at the Dana Farber Cancer Institute and Harvard Medical School. Jane, welcome to the GeriPal podcast.

Jane 00:37

Thank you so much for inviting me.

Alex 00:39

And we’re delighted to welcome Ishwaria Subbiah, who is an oncologist and palliative care doc and is executive director of Cancer Care Equity and Professional Wellness at the Sarah Cannon Research Institute in Nashville, Tennessee, and also oversees wellness for us. Ishwaria, welcome to GeriPal.

Ishwaria 00:59

Such a pleasure to be here. Thanks for having me.

Alex 01:01

And we’re delighted to welcome back to the podcast Naomi Saks, who is a palliative care chaplain, assistant professor in the Division of Palliative Medicine at UCSF and Director of Individual and Collective Well-being for the Hospice and Palliative Medicine fellowship at UCSF. Naomi, welcome back to GeriPal.

Naomi 01:18

Great to be here.

Eric 01:20

So we’re going to be talking about wellness and resiliency, or even if those are the terms that I should be using now, because everything seems to be changing. But before we do, I think somebody has a song request for Alex. Who has a song request?

Naomi 01:34

I do.

Eric 01:35

Naomi, what song?

Naomi 01:37

Beautiful, by Christine Aguilera

Alex 01:39

Oh, Beautiful. Beautiful. Thank you.

Eric 01:54

Why’d you pick this song, Naomi?

Naomi 01:57

Because it really talks about this beautiful experience of our beloved, which is ourselves, the part that we often cut out of the equation. And so I just thought it was really beautiful.

Eric 02:09

Thank you. Alex…

Alex 02:12

(singing)

Eric 03:16

That is a lovely song. It’s been a while since I heard it. Thank you, Naomi.

Alex 03:21

Beautiful words can’t bring me down.

Eric 03:24

Okay, I’m going to start off with the question that I had earlier. I think we titled this wellness and resiliency, but I see a lot of words that are being bantered around. I even heard in people’s titles. So wellness, well being, resiliency, burnout. How should I have titled this? Naomi, I’m going to turn to you. Thoughts on kind of where we are. I know you work with our fellows a lot on this. How do you talk to them about these terms and these definitions?

Naomi 04:00

So, really good question one, I always let people name their own experience. So that is one of the things I’ve learned, and all the people I work with teach me is actually, we ask people what they call it, what they call their experience. But there’s been a big shift, I would say, in the last five or ten years of programs that focus on this idea that if you just were good enough and better, we’re going to burn you out and ask you to do yoga afterwards, and if you were just strong enough and more organized, you could take care of yourself. So people are not so excited about this idea of resilience in the old fashioned way, this idea that it’s up to you. If you were just. If you could make it, if we.

Eric 04:44

Could just make you a little bit more resilient, you can increase your Rvus so you can see more patients. So we’re going to mandate you take this mandatory resiliency training after work on this online module, right?

Naomi 04:59

So we know that we in healthcare, and all of our colleagues are some of the most resilient people that ever existed. I mean, in other work, hard work environments as well. But that’s where it extended to this whole idea of well being or flourishing, or wholeness or sustainability. This is this idea that 80% of burnout or moral injury is actually systemic, and only 20% is actually how we relate to that. And that’s how the names have really changed.

Eric 05:27

80 2080 20.

Ishwaria 05:29

And that’s really how this field of professional well being, healthcare professional well being, clinician well being, has evolved, is that there is an important place in our overall professional well being for personal resilience and our individual coping strategies, recovery methods from day to day. But we can’t lose sight of the system level, the x individual outside of the individual, the system level factors that inform our day to day workplace experience.

And so, in that way, the frameworks developed out of the national academies, Mayo, Stanford, they really all align around personal resilience. Being an important part of our professional well being. But allowing the space in that same breadth to say it is actually mostly organizational factors, organizational culture of wellbeing, efficiency, of day to day work, life and practice being the other main components that complement personal resilience. So we’re not going to meditate our way out of this one, is what we’re saying.

Eric 06:41

But meditation or there’s some personal aspect that still matters. That right. So it’s not 100% systemic or systemic. Systematic, absolutely.

Naomi 06:55

Connection. There’s all these gold standards from positive psychology that are still so important, and also from all the wisdom traditions, spiritual traditions, existential meaning making connection, pro social emotions, this gratitude, these emotions that make us feel good inside, and then they help us connect to other people. All those things are still important. This whole idea of mindfulness taking a pause, perspective taking, all those things are really important in changing how we experience what was going on, because it isn’t actually what’s happening, it’s what we tell ourselves about what’s happening.

Alex 07:30

Jane, as long as I’ve known you, you’ve struck me as somebody who has been really adept at finding a within yourself the balance and being attuned to what you need in order to have a fulfilling career, fulfilling personal life. And, I don’t know, back in the day, you know, to push on the terminology, we used to call this work life balance that’s probably falling out of favor. I don’t know. Yeah, probably. I’m seeing some nods. Probably not the term we use anymore. I’m wondering how you think about this issue.

Jane 08:04

So, first of all, it’s such a lovely compliment, and I want to just savor that for a minute, because I actually think it may reflect the phenomenon of how people look from the outside. Like, it sounds like the way that you experienced me. And sort of what I was conveying was that I had great work life balance. And internally, that was not my experience. My experience was that it was wild and that, you know, I think as a single mother and as a junior faculty person somewhere like Dana Farber, it was easy to feel like I was falling short in a bunch of different directions.

Not that I had it all under control. And I do think that one contributor to our sense of sort of unease or the frantic feeling is that we compare what’s happening to us internally, the mess behind the scenes. Honestly, if you saw. I’m in my dining room right now, if you saw what was happening, I’m in the middle of packing. And so chaos, like, behind the computer, is chaos. And it’s like, a little. Little example of what I’m talking about. So, we compare that to what we see from the, you know, on the outside of the people that we know and we work with. So that’s. That’s just one note that maybe we can explore further.

But to take the compliment at face value, I do think that something that I’ve really aimed for over years is to pay attention. Is to pay attention to what’s happening internally, is to pay attention to what’s happening around me and pay attention to what’s happening in the people that I’m responsible for, including my trainees or my coworkers or the people who are in the program that I led for some years. And I think everything that we’re talking about in this time and that we will talk about probably has to start with this idea of paying attention.

Eric 09:58

And I just want to acknowledge, too, because I’m going to compliment you, too, Jane. I’ve known you since we did PSAP together, I think, back in 2007 ish. But even today, the first thing that you asked me is how my son was doing. And we didn’t even ask how my son was doing. You said, how was Kai doing? My son’s name? And I just. It shows that you don’t just. You’re not paying attention just to, oh, how’s work going for you, Eric? It’s this larger acknowledgement as me, as a human, human being in this crazy world that we live in. And then there’s more to me than work that feels, Jane, like something that, I don’t know, I wish I did more and could pay attention to more. It feels like a practice of yours in some way.

Ishwaria 10:45

There’s something to be said for being seen as a whole person, even in the workplace environment, because it’s you, truly. There’s no such thing as drawing a line between work and home.

Eric 10:57

Yeah.

Ishwaria 10:58

You’re thinking about things outside of work during the work day. You try to keep it down as much as possible, but there are still things that weigh on your mind, and rightfully so, because you are one person, you’re a whole person.

Eric 11:10

So it’s not really work life balance. It’s more like work life, like integration. We’re putting it all together.

Ishwaria 11:15

I just think of it as coexistence.

Alex 11:19

Quick plug for the show severance on Apple, where the main character has severed his work life from his personal life. In fact, his brain is divided in two, and the work life person doesn’t know what happens in the personal life and the personal life part of his brain. Doesn’t know what happens in the work life. That is the opposite. And obviously, it leads to a lot of problems, which shows why this is problematic. I love the extreme.

Naomi 11:48

Yeah, I kind of think about it as remembering. That’s why a lot of the people I work with call it wholeness. You know, our training was invented in 1889. It’s pretty much the same. It was even before the weekend was invented. And we’re asked to banish huge parts of ourselves off in our training. And then it continues. We’re told not to pee when we need to pee, not to eat when we’re hungry. And we’re actually told that it’s not professional to be emotional. These kinds of things, they run deep and they get into our DNA. So it takes a while to rehydrate and to remember that. That actually, we will not show up less than whole. And that’s a revolutionary act. Like, we love this work so much that we will no longer banish parts of ourselves off.

Eric 12:35

I think that’s a beautiful concept. And I wonder how. What do we do to achieve that? Naomi? Because it’s certainly not the way I’ve been trained.

Ishwaria 12:45

It’s. We don’t see. We don’t often see that kind of. I don’t want to call it behavior, because it’s. It’s part of just being a human. We don’t often see that modeled. Right? We don’t often see that. We don’t often bear witness to that, at least in. When we look at those who are further along professionally than us. And so in that way, it’s. There’s something to be said for bringing just enough authenticity. It’s not that you bring all of your problems to work, or you bring all of your work problems to home. Those people who may not have, those who may not share a bit of the whole picture on how they’re doing at work, especially leaders, they’re going through things. It’s not that their life is not a bed of roses for them. And so in that way, there’s really a missed opportunity there for mutual gain from getting some validation of what’s actually on your mind and still using that opportunity kind of reset and focus on what you wanted to accomplish that day versus having whatever’s weighing on your mind just persist throughout the day.

Jane 13:58

I’d love to hear Naomi’s perspective on this. I feel like this is maybe in her wheelhouse, but building off of what Ishwaria just said, the idea that we have the capacity, the facility, to bring our whole selves to work but then also the discipline to know which facets of ourselves to bring to whatever the situation is that we’re entering. So whether it’s an encounter with a patient or whether it’s a family meeting or a clinical practice meeting or a feedback session with a fellow, the idea that we have both the ability to be very full and open and also selective and disciplined about how it is that we. What parts of ourselves that we bring into each particular moment. And, Naomi, I don’t know if that resonates at all for you.

Naomi 14:50

I definitely think, and I love Jane, how you keep coming back to the moment, because that’s all we have. We don’t have a past and we don’t have a future. And the moment, especially in our body, which is something we’re not usually trained to do, is to really to check in with ourselves, to scan and see where we’re triggered to, where we need a little attention, are we tasting our food? Those kinds of things. But I would say, even for me and for the colleagues I work with, the first thing is saying, we work for institutions that were not built to take care of us. In fact, we live in systems that are oppressive.

They’re often racist. They often do not invite our whole selves there. The work of Tricia Hersey with rest is resistance. This whole idea that our worth is not equal to our productivity. Like, just even having that and normalizing it, and, like, after 13 years of training or 15 or whatever, chaplains, nurses, social workers, patient care assistants, everyone is working in these systems that are not built to take care of them. And I think that’s just, like. It’s actually a relief just to say that. I think it’s important. And I would say we still don’t know how to do this. We are bright and amazing and compassionate and dedicated humans, and we still do not know how to completely sustain in these systems and flourish in systems that depend on us to overwork and actually have censuses and groups of patients that are more than we can handle until we get more resources.

That is the basic business plan and strategy of the institutions we work in, is basically to say, we’re going to make you work so hard and have so many patients, then we’ll finally give you resources, like, just that. And then it comes back to exactly like, okay, today, how am I going to sit here? How am I going to continue to be in this? So that I think it’s both.

Eric 16:47

I really love what everyone’s saying because it is interesting. Part of it is, how do I stay resilient in a broken system. And when the system does acknowledge wellness, it sometimes feels authentic because it’s their solution to decreasing productivity. Rvus. It’s like the development of an EHR. It’s really not about helping the patient or physician. It’s all about rv in billing.

Ishwaria 17:15

Billing.

Eric 17:16

Right.

Alex 17:17

Feels inauthentic.

Eric 17:19

And I wonder, AIshwaria, coming from your perspective, like, you’re leading wellness for two organizations, including your work, you have a leadership role in that. Like, how do you think about this from a systems perspective? Because I think it’s really easy for somebody like me to say, oh, like the C suite, they’re just bad people and they don’t care about us. And it feels like I can, you know, talk with my colleagues and, like, we can share stories about, like, war stories, but they’re people too.

Ishwaria 17:58

Yeah. There’s something to be said for thinking of stepping back and recognizing that the system is an inanimate entity, that the system and the culture that comes with it are perpetuated by people. And so in that way, it’s not the letterhead or the four walls and the roof that are perpetuating the present, it’s the people. And so in that way, if we’re looking to advance the workplace experience in any setting, in any setting, in any role, and definitely within healthcare and definitely within oncology and medicine and geriatrics, is, you’re going to have to recognize that efforts to optimize will be centered on partnership and aligning as quickly as possible on the shared goals to the earlier point made.

Systems should care for our wellness because it’s the right thing to do. But it may be that staffing shortages, high turnover, high cost of recruiting, training up a new physician nurse app, really any role that that’s the driver for the inanimate system to suddenly pay attention to, why are people leaving? And so in that way, that effort to maintain the systems momentum was a driver behind having a leadership presence in many organizations across the, in many healthcare settings across the country. For a team that’s tagged with professional.

Eric 19:44

Well being, is that usually the cause? I hear more and more places have chief wellness officers.

Ishwaria 19:51

It’s a role that’s built to be one where that leader sees eye to eye with the chief financial officer, with the chief information officer, with pick any other C suite member. And that role is meant to drive that organizational culture of wellness. So that the norm isn’t you’re going to have to demonstrate the need for these three ftes yourself, and then we’re going to give you one like, that’s. That’s organizational culture, wellness. It’s not whether we have a mindfulness moment between the 14th and 15th meeting of the day.

Eric 20:34

Yeah, it’s.

Ishwaria 20:35

Do we ask somebody to do the work of five and then give them one fte?

Eric 20:42

It feels like from a, you know, the chief wellness officer, it. It could be viewed as two different ways. We are offloading wellness on this individual who doesn’t have a lot of power to make change, but we can scapegoat all our problems on this chief wellness officer. They can put together some pizza parties and stuff like that while we deal with the real business at hand. Versus what you’re talking about, too, is this integration of the chief wellness officer into that c suite where they actually have the funding, they have the ability to change things. And it’s not just we’re pushing all off these duties on this person so we can say we’re doing something on wellness.

Ishwaria 21:26

It allows a role like a chief wellness officer or really any executive role in professional well being, allows for the quantification of professional well being through the validated measures out there and measures that not just share what the burnout rate is, but measures that go into the driver dimensions of burnout so that you, as a chief wellness officer, can say, oh, it’s not because I haven’t done any meditation retreats that our people are burned out. It’s because, look, they have finding very low meaning in work. Their EHR helpfulness score ranked painfully low. And so, in that way, by having objective measures of well being, you’re taking a lot of the perceptions out, especially one surrounding that there’s a resiliency deficit that needs to be corrected in order for burnout to no longer be a problem.

Eric 22:28

Yeah.

Alex 22:29

Jane, I remember back in fellowship where a couple of instances when we push back on leadership about stuff because our work was just becoming unbearable. And I remember we did it once with Susan block over the IPCo and another time with Andy Billings over coverage issues. It’s been a long time since then. That was like 2005. Over your career, have there been times when you’ve advocated either for yourself or for your colleagues with upper level leadership? And now that you’re in upper level leadership, what’s your view of this as you’re helping people who are coming up through the system grow and develop professionally?

Jane 23:13

There are a lot of parts to that question. Alex.

Alex 23:16

Sorry.

Jane 23:17

No, no, it’s fine. So, I guess I’m going to choose the part that I want to answer.

Alex 23:24

Good.

Jane 23:25

Which is, you know, I have had a few different kinds of leadership roles, and one was, as clinical director for our clinical service at Dana Farber and Brigham and women’s, overseeing the clinical operations for our whole fairly large group. I backed into that role. It wasn’t sort of a strategy to be like, oh, I really want to do a clinical leadership role. And then found myself in that role during the pandemic and learned some things about myself that I didn’t know. Namely, I actually like working in a crisis. I can make decisions quickly. Like, there were some things that I was like, oh, look at that. And also, by the fall of 2020, I was pretty sure that I didn’t want to be a leader anymore. And so I’ve spent the last couple of years actually backing out of leadership roles because that position of being sort of caring deeply about what’s happening for people who are doing the face to face patient encounters and doing that kind of work, and the administrators who are making decisions and sort of being in between those forces.

And then, and sometimes even on the role of the administrators making decisions, especially in the context of a pandemic, became so heavy that it was. It was hard to keep my balance. The role that I have now is one where I don’t have people who report to me. I don’t manage anybody, but I get to sit in on some leadership meetings and make my voice heard. And my role is to try and be as thoughtful and as observant as I can be about what’s happening with people in our group, in our department of about 200 people, and figure out where the places where people are really thriving, where are the places where that’s less the case?

And what are the interventions that I could imagine that might help the places, you know, for the people who are in the spots where they’re not doing as well? The very long winded answer to your question, that has a little bit to do with leadership. But also for me, I found the level, the happy point, where I could be in a position where I could be helpful, where I could use the skills of observation and desire to help someone grow without getting banged around quite so much in the big institutional politics and decision making over life and death, things like what happens in a pandemic.

Alex 25:58

That’s great. Yeah. It sounds like you’ve found within yourself what you need in order to be able to thrive in your role, and you’re helping others identify those areas where they’re thriving and not thriving. That’s true.

Jane 26:10

That’s it.

Ishwaria 26:11

I hope we all have a jane in our workplace and in our departments and in our practices, our clinics, labs like we need.

Jane 26:20

Maybe we just take this fivesome on the road, but there’s.

Ishwaria 26:24

There’s. There are things we can teach one another to heighten our self awareness. Right. The way that we’re reacting in a moment to something we’re observing, to be able to recognize that in the moment and past likely validate it. Right.

Jane 26:38

It’s.

Ishwaria 26:39

You’re reacting appropriately to what you’re facing. Now. Let’s find a way to reconcile with that a little bit here, a little bit afterwards, and then let’s preserve some of that cognitive bandwidth for, okay, what can we do next to help that patient, that family? What can we do next to help that colleague? And so there’s something to be said for having peers who are peer leaders in the workplace, who have that level of observational awareness on what others are going and to help them recognize in the moment that this is affecting me in the way that it should, because I’m a good person and I should be reacting this way.

Naomi 27:22

Jane, I really relate to what you say. You know, us in palliative care, we’re fueled by death anxiety, by a lot of loss. We’re supposed to be the people, the comfort business people. We’re supposed to go into the center of human existence and just make it better. And during COVID that kind of broke apart for me. I was always in leadership positions. I was a director of our palliative care team. I was a spiritual care director, and I kept it together pretty well. This idea of I was supposed to be the compassion person. I was supposed to always come in and bring calm. And actually, that broke apart. During COVID there was no calm.

There was no way to keep it together. And I actually couldn’t take care of the people that I was supposed to. And at first, it was so painful, and then it was just a beautiful relief. There was a moment of, like, a death, and then, actually, there was this moment of, like, actually, I can be. I can show up much more fully now than I ever have been before, and I don’t. I don’t keep parts of myself away. And I also don’t assume that I’m gonna be the person to be able to swim into the death anxiety, to swim into the loss, to people’s fear of aging, to people’s fear of dying. And I didn’t think I needed to make it better. But chaplains, especially during COVID were the ones that were just sent in there. We were often the only ones left in the hospital. We went into the rooms.

And there was, like, a feeling of, oh, right, we’re valued now. And that was really great. And we never let a good emergency go to waste. So we got more ftes that way, too. But at the same time, I had such compassion for our leadership, for me being in that position. And I continue to know that, like, this is, like, nobody’s getting out of this, like, in a perfect way. But I just really relate to sort of your own personal journey, because I think I’ve had my own with this.

Eric 29:12

Naomi, what do you think it was about COVID pandemic that broke so many of us? Because I do feel like that the same thing happened to me is that part of my goal of the last two years was actually to give up some of my leadership roles, fellowship, leadership roles. Other things focus more. And it’s probably just until recently where I, like, I’m finding those things that bring me joy again and attending things I haven’t done in a while, like our works in progress meetings, which I never really attend. It’s more research meeting, but I kind of get joy out of it. I go to M and M’s again because I still kind of get joy out of it. So trying to find those things because I hear this over and over again, I think Covid broke a lot of us.

Naomi 29:56

Yeah. For me personally and also for a lot of people, my friends and colleagues, we couldn’t keep it knitted together. That was the bad news and the good news, and it was so unknown, and everyone was so traumatized. And right down from leadership down to the whole. Anyone in the whole organization didn’t know what to do. And we all were kind of acting from our feet, doing the best we could. And then I couldn’t. I didn’t have enough energy to also knit a Persona, professional identity, or even a sense of, I actually can fix this, or I’m a leader, and I’m going to take care of people.

And it was horrible because I was like, this is not what I signed up for. But then there was just after I let just surrendered to that. Same with me, Eric. Joy just comes into my life now. All I want to do is like, okay, let’s have fun. Like, let’s. Let’s just do some crazy thing at work. Let’s have fun. Let’s go out. There’s some just joy that’s bursting inside of me from that experience of this identity, this professional identity breaking open. But it was hard for a while. I couldn’t get help. I couldn’t get anyone to. We couldn’t make it better. There was just no way. Yeah, it was a dark night.

Ishwaria 31:07

You know, Naomi, you hit on something as you were sharing that. That. That really resonated with me, and that’s. You can’t be everything for everybody, and it’s not. This was an element of my professional growth, especially as I hit that mid career stage. At the start of the pandemic. It was having to reconcile with the fact that I was getting responsibilities and needs shared of others that I could meet. From a skill set standpoint, it’s within my scope of practice and palliative care and oncology. But there physically wasn’t the time, and there wasn’t that energy to be able to do everything for. It was pushing ten boulders up a mountain instead of just, you know, one. It’s just not. You cannot be everything for everybody. Even if you’re trained to do it. You just can’t.

Eric 32:07

Yeah, I felt like the first year, I actually had a ton of energy. Like, it was a sprint, and then, like, I ran out of energy and just. I had nothing like. And the fact that it just kept on going.

Ishwaria 32:22

Just kept on going. Any Hollywood virus movie, there’s a resolution in, like, three months, it’s done, and the world goes on.

Naomi 32:32

I had family members pounding on my chest in the lobby, wanting to get up to their patient’s room and screaming at me and calling upstairs that their loved one was dying. There are stories that are stuck in here that need definitely.

Eric 32:45

Look, let me ask you about this thing, because we’re talking about wellness and resiliency, but I think the other big thing that we saw a lot was moral injury. We want that family to visit their loved one as they’re dying, but we have no control. There’s some things that are completely out of our control. We know it’s not the right thing to do, so we feel this injury deep in our souls. Do you think that played a role? And how do you think about moral injury, Naomi?

Naomi 33:15

Well, you know, for palliative care, like, our baseline is, okay, we can’t save you, but we can at least give you a nice death as best as we can. Like, that’s, like. That’s the assumption. I know that’s a myth, too, but it’s kind of what we hold in our hearts. We can’t. We can’t cure you, but at least we can give you a nice death. And so that was gone. And so moral injuries, this whole idea that I think of, and Cinder Rushton was the one that really put this on the map. For us. But it’s really this idea that I know the right thing to do, but the system won’t, or the.

Or the situation won’t let me do it. And so I really feel like that idea is really this idea of, like, how there’s also moral resistance. Now it’s called moral resistance, which is this, and moral resiliency, which is this idea of how to be. How to be fluid and to be, and to respond and to have perspective taking when we don’t have control. And Covid was just. Just an amazingly startling example of what we didn’t have control. We’re not making this any better.

Eric 34:17

Yeah. Individuals had no control. Systems had no control. Like a loss of control in every layer as we think about next steps and how to help with wellness, well being, resiliency, however we want to call it. I wonder if we can use this time, because we’re getting close to the top of the hour. We can think about, like, on those different levels, the individual levels, the system levels. What are the things that we can do to improve the well being, the wellness of individuals? I’m going to go ahead.

Alex 34:55

What have you seen to be effective at your institution or other institutions?

Eric 35:01

Jane, I’m going to start off with you.

Jane 35:04

I was hoping you’d start with AIshwaria.

Eric 35:07

I was thinking about that from a big systems wellness perspective, but I’m going to mix it up a little bit. You’ve worked with a lot of trainees, a lot of people on the service.

Jane 35:19

I have. So I have a few thoughts about this.

Ishwaria 35:24

Go ahead. I’m ready.

Jane 35:27

One is part of what I really try and help people do is, as has been commented on a little bit during this time, is to see and to validate people’s experience. And so if I’m precepting a fellow and we come out, and sometimes it’s that, I’ll see that there’s a struggle. I can help give words to that, or I can share my own. And so that person isn’t so alone. Whatever it is, it’s to give it form, give it a name, give it some shared currency. And in that is a sort of nurturing of what I think of as authenticity or belief in your own experience. Experience and a practice of understanding that something’s happening and then going after it and trying to figure out and define what that is and articulate what that is. So maybe I’ll just start there. There are some other things that I think of along those lines, but this idea of authenticity and sort of hand in hand with that goes a shift. And this is sort of like the second piece of going from should to want to. And so, like, we have all of these shoulds that are imposed. Sometimes they’re internal. We grow up.

I should be a good person. I should be generous. I should be whatever it is and learning to figure those out and sort of parse. What are the ones we should actually listen to and what are the ones that we can actually let go of and the external ones as well. We should be writing. We should be doing this. We should be doing that. What are the things that I. That, as you were saying, Eric, that bring me joy that I can pursue because they feed me, as well as whatever the reward system that I’m in.

Eric 37:09

What’s that person? Is it Marie Kondo or something like, you get rid of the things that don’t bring you joy?

Jane 37:16

Yes.

Ishwaria 37:18

Bring the closet cleaning philosophy to life. Good to know.

Eric 37:25

Naomi, I wanted to get your thoughts. I loved your title. What was your title again?

Naomi 37:32

Individual and collective well being.

Eric 37:34

Individual and collective. When you think about individual and collective well being, what works in each of those two categories?

Naomi 37:42

Yeah. So, obviously, as a chaplain, the internal life is sort of my playground. And so I think the first thing is actually that 20%. Are we paying attention? Are we noticing? Are we taking dearest care of ourselves? Do we taste our lunch? Do we let ourselves actually sleep long enough? Do we say no, even when it’s hard? Are we not pathological, altruist? Are we allowed to actually take care of ourselves? And then do we take moments of mindfulness, moments of respite? So that’s really important. And then there’s all those gold standards that I mentioned earlier, meaning making connection, prosocial emotions, processing grief. Like, we are not ever included to do that.

But then there’s the bigger systemic thing of actually baking in well being. Not as a check mark, not as an extra, but making sure that it’s in clinical practice, education, training, and research and DEI and this equity and inclusivity aspect. And so that means that everything from do we take a break after we go into a family meeting? And it’s really intense, do we actually give ourselves a moment to cry, to actually changing workflow, to actually advocating for hiring more people or creating research teams that show outcome and financial base, interprofessional teams. So when we were working on this book, intentionally interprofessional, we found such strong evidence that the team itself, simply being in a team, is protective. It’s completely protective. So those kind of things are really important to look at it both internally and then also this whole larger view.

Eric 39:21

That goes to you, Ashwari, as you’re thinking about this from a, a systems perspective, what have you seen that works?

Ishwaria 39:30

You know, it’s recognizing that one of my favorite quotes is from Christine Sinski over at the AMA. It’s not you, it’s the system. And so it’s us within healthcare as a whole, pausing for half a second and validating ourselves and our reactions as this is us reacting to the stimulus that’s presented. I am not the one. I don’t need to be fixed. There are things I can do better, there are things I can learn more and do more of, and I’ll do that. But the present is not because I, as an individual healthcare professional, am not enough. And so in that way, the system level solutions are validating professional well being as an organizational responsibility and infusing that culture of wellness into every single discussion, conversation, initiative, it build, quality improvement, whatever.

You know, every single table has to have at least one leader who would already be there anyway, who has that lens of impact of what we’re proposing on the workplace experience of those who will touch that initiative. What is the task load burden? Actual task load burden? What are we going to take off their plate if we’re going to put these additional seven tasks onto their plate? For a, you know, to meet some quality measure, do we really need a 15 character password? If ten would do, do we really need the computers to timeout after 15 minutes? If we can safely do it, extend the timeout period to 60 minutes.

So the well being as an organization is recognizing that it’s not the catastrophic losses that we may have on occasion that affect our day to day professional well being. It’s the accumulation of the micro trauma, the micro injuries that we are taught to just get over, take a deep breath, shake it off and move on. No, the injury accumulates, and it accumulates to the point where you can’t tell why you’re feeling so heavy when you walk into work or when you get out of bed. It’s the organization’s priority and responsibility to ensure that work that’s being done. A metric of impact and a metric of outcome is centered on the people.

Eric 42:19

Yeah.

Ishwaria 42:20

And it’s possible.

Eric 42:22

Yeah, it’s one of those challenges too. It’s like the organization, like every organization, things build up over time. Meetings build up, all of these additional things build up. We were just in an m and m where there was a bad outcome. Like we have these, we look at these outliers and then there’s a desire to change our practices based on these outliers, which adds more things. Somebody had a hyperglycemic event, so we’re going to check daily, three times a day, blood sugar sugars on everybody. So instead of it, I like what you’re thinking about this, is that there should be some potential pushback. We’re thinking about, what does this mean for. But everybody in this system, the patient, the providers, is this the right path forward?

Ishwaria 43:08

Exactly. And you shouldn’t, as a system, hesitate to de escalate. De implementation should be in the same breath as innovation and any other buzzword.

Eric 43:21

Yeah, because we often talk about even like, interprofessional collaboration, how great it is. But there could also be excessive collaboration where you have so many meetings at conference calls, you can’t get anything done in your life anymore.

Naomi 43:34

I found that after Covid, everyone just sneaks a Zoom meeting and, like, that’s not real time. I’ve never had so many meetings in my whole life. I don’t know about all of you.

Alex 43:44

Yeah.

Ishwaria 43:44

Things that would be hallway conversations at the coffee shop, at the cafeteria are now a meeting. That sense of community in the workplace has changed substantially, and we don’t know the mid or long term impact, and we truly don’t know how it’s going to affect professional well being.

Eric 44:06

Do we have time for one lightning round question for each of you? Is that okay? It’s a magic wand question. I see nobody saying no. So I’m going to take this opportunity to extend this podcast just slightly. So if you had a magic wand around wellness or resilience, you can focus on individual listening to this podcast. A system, our society. What would you use that magic wand on? Ishwari, I’m going to start off with.

Ishwaria 44:32

You when I think of the pandemic. My magic wand is for each person to feel control of shaping their professional life and their professional legacy. That the work that you do doesn’t have to be every single thing you do, every single. But the work that you do, if you sit back and reflect, has to align with your. Why? Why did you go into this field of work? And is the work you’re doing as a whole making you feel like, hey, that’s what I set out to do. And if the answer is no, for crying out loud, change the. Change your job internally, within your organization. Actively explore what opportunities there are to evolve your focus and your functions. If not, find the place that does.

Eric 45:29

Yeah.

Ishwaria 45:30

Nothing has to be wrong in order to move, and that’s something that we have to really be comfortable with in healthcare as healthcare professionals is. But to change, you don’t have to be on fire before you decide that something needs to change.

Eric 45:47

I love that. Naomi, what’s your magic wand?

Naomi 45:52

Well, we had a beautiful ed resident that was rotating with us last week, and she said, naomi, what would it look like if this system was built for me and for my well being? And I go, that is a great question. So my big fat magic wand would be reconceptualizing this whole problem and actually reconceptualizing healthcare into healing and centerpiece love, compassion at the center of that, and rethink about this whole idea of how, how do we invite people and train people and what are we inviting to them in this healing art that we’re doing? And it would completely reconceptualize. We talk about the fourth aim of well being, being part of it. I would get rid of the first three aims and reconceptualize that and say, really? Is that for the best and good for everybody? That’s the wand I would want to use.

Eric 46:41

I love that. Jane, you’re the last one. I gave you the last one this time.

Jane 46:45

I know, and I’m still going to complain about the order. Who can follow Naomi with those answers? I love what both of them have said. Naomi is like, basically reconfiguring healthcare completely and reprioritizing it. And it’s amazing. I want to go there. But what Ishwaria said is something that I’ve done a lot of thinking about as well, and to sort of pull palliative care and this topic of wellness and sort of career and work and fulfillment together, you know, if the gold standard in healthcare or in palliative care is goal concordant care, and that’s we’re aiming to figure out what people’s values are, who they are, what’s happening in the context of their illness, and then create a plan that matches who they are in that journey, then what I would aim for, for people that I work with, for myself or anybody in healthcare, is goal concordant careers.

So the idea that we, we take who they are, what they are, figure out their priorities, that they do this for themselves, that they know themselves well enough that they can learn their own priorities, their own goals, their own passion and mission, and that their careers reflect that. And I think when we have people who are working in situations where they can do that, where they can use the best parts of themselves, where their sense of mission and the difference they want to make, they can actually do that. They’re effective. Then thinking about wellness, it starts to skyrocket.

Eric 48:14

Yeah. And I think both for the person and I just want to bring in one thing Ishwaria said earlier is systems are made of people.

Jane 48:21

Yeah, exactly.

Eric 48:24

With that, I want to thank all three of you. But before we end, Alex, do you want to give us a little bit more of Christina Aguilera?

Alex 48:32

(singing)

Eric 49:36

Ishwaria, Naomim Jane — thank you for joining us on this podcast.

Jane 49:39

Thank you.

Naomi 49:40

Thank you. Wonderful to be here.

Ishwaria 49:43

You are the best. Thank you.

Eric 49:44

And thank you to all of our listeners for your continued support.

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Disclosures:
Moderators Drs. Widera and Smith have no relationships to disclose.  Guests Jane Thomas, Naomi Saks, and Ishwaria Subbiah have no relationships to disclose.

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