All right, I think we're going to move on to our next panel. This is our second to last session before happy hour. So at this point, I want to invite Judy Jacobi, Steven Pastores, and Rob up to the stage, please. So our next session is entitled Keeping It Fresh, Finish the Race Well. And we really want to focus on longevity of critical care. And we thought a good way to do this would be, I think I'm going to have each of them do like a 5 to 10 minute introduction of themselves, their career, and what they think would be best for you guys to know. And then we're going to open it up for questions for the next 20 minutes or so. And please, think about questions that you want to ask them as they talk. So maybe we'll just go down the line and start with Judy. All right, well, thanks for hanging in here with us. This is fun. I'm just really excited with your engagement and hope you will give us some suggestions for future improvement or other things you'd like us to see. I was a critical care pharmacist at the bedside for 38 years. Resisted the urge to, I dabbled in administration and realized quickly that that wasn't where I wanted to be. Really loved the engagement of my team, in particular being part of the action on the ICU and pretty much worked in every ICU in our large level one trauma center. But well, probably in the last 10 years or so, found that I was mostly in medical ICU. And then my boss said, all right, I really need you to switch to cardiothoracic ICU. And I resisted as long as I could, but lost that negotiation and ended up in cardiothoracic ICU. And so it was honestly, later in my career, just an amazing time to suddenly really have to learn some things that I only peripherally knew, ECMO, ventricular assist devices, all the new cardiac procedures. And so honestly, it was a really stimulating opportunity and a wonderful new challenge. And so I think that was probably one of the things that was a theme for my career, is embracing new challenges. And certainly, that always happens at the bedside. You never know what you're going to be faced with. And there were new therapeutics. But a lot of it came with professional organizations like SCCM, where being involved gave me the opportunity to network with amazing people, meet amazing people like you. Gave me the opportunity to develop my leadership skills, but other skills in terms of being up to date with cutting edge everything. And knowing who to go to when I needed assistance, and just having that really strong network. And so it was a way to really bolster my interest, my career, keep me stimulated with new things, and give me the opportunity to take it back to the bedside. So my colleagues always hated it when I came back from a meeting, because I came back with a list of things that we could do differently or better. And they were like, oh my god, here she is again. So I didn't have a single tangent and pathway, but just lots of opportunities along the way to keep things exciting. And honestly, I ended up retiring before I anticipated, because I was in cardiothoracic surgery. And I did not have evening shift coverage. That's a situation that's changed at my organization now. I should have just stuck it out a little longer. But who's in the OR the longest? The sickest person. Or when does that ECMO patient get transferred in? It's not at 12 noon. It's 8 o'clock or 9 o'clock at night. And so if I knew that was going on, then I felt compelled to stay with my team as well. And so at some point you say, gosh, this is fun, but I just am ready for something else. Thank goodness for SCCM. So I left the bedside, but have stayed very engaged with SCCM and professionally, scholarly work. And now mentoring has become a big part of what I've been able to do. People have reached out to me from around the world, literally, to say, hey, I'm looking for some ideas. Can you help me? And thank god I now have the time. I don't know that I would have when I was working full time. But so there's lots of ways to stay engaged professionally through an organization or that network you've established. And I also kind of simultaneously, because apparently I can't stop volunteering for stuff, got involved in a local food pantry, just as somebody distributing the food. And now I'm the treasurer. And as a result, I'm now the grant writer, because we need more money. And so I've been blessed with the opportunity to find those other things in my life that have enhanced me personally, professionally, spiritually, and within my community. So it has to be a little purposeful at times to kind of say, what is the next thing I want to do? But it certainly can be rewarding. Great. Thank you, Judy. So I'm Steve Pastores. I direct the critical care medicine program, research program at Memorial Sloan Kettering Cancer Center. I've been your typical academic internal medicine, pulmonary critical care practitioner. I still do bedside care. I practice 20 weeks in the ICU and in the consult service, rapid response. I'm very active at the bedside. But I also do a lot of teaching. I've been program director for a little over 20 years. And so I've graduated over 150 fellows. I love teaching, not just fellows, residents, medical students, but also advanced practice providers and nurses and respiratory therapists and nutritionists. Our conferences are multidisciplinary. I engage everybody. But I've also been very active in the Society of Critical Care Medicine. I've been a member since the early 90s when I was a fellow. I was really spurned into that interest based on my desire to do clinical trials. So fortunately, being around giants like Phil Dellinger, Joe Parillo, Tommy Birdy, and the likes, I really got a passion for doing clinical trials. So I do clinical care. I do education. I do also administration. And I'm also a clinical trialist. But SCCM, I think, was my really true society. I've not only been a national and international ambassador for the society going around the world, doing national and international board review courses, best of SCCM courses. I've met so many people in leadership at different societies internationally, and that's been, I think, a very good opportunity to meet and see, not only understand people, culture, how they run ICUs. But I think my joy in the profession, and I've stayed this long, is really because every July, I'm always excited to see new people coming in. And training, and those who have graduated will already know my own stick-on rounds and what I like and don't like. And so it's always good to see new blood coming in, and they'll always see you as somebody that maybe knows a little bit more. And so I find that very, very rewarding. And of course, family is key as well. My wife is also a doctor. She's a hematologist at Weill Cornell. And so we're both very active. Just like me, she's very much engaged in all the same things that I do. And then our two adult children are really our inspiration and the loves of our life. And so we love traveling together. So you just have to maintain that constancy of joy and fulfillment in the profession, be able to give yourself some space and time, take time off, travel. I love sports, movies, Netflix, you name it. You have to give yourself time. There are disappointments and challenges along the way. No doubt about that. Some family issues, things like that happen. But you just have to go back, reflect, and enjoy the moment when it comes because sometimes life is too short. So you gotta, as they say, enjoy that lemonade in the park as famous Roger Bone used to say in the early or mid-90s when he established those essays and published them. So yeah, that's my story. Well, it's a privilege to sit here with two critical care legends. I've been involved with critical care for a little over 40 years. I actually went to a PA, most of you know that PA programs are general medicine and then the PAs go into the working field and specialize. I actually went to a PA program that trained me in critical care because I knew I wanted to do critical care. I had just gotten out of the army and I was employed in a hospital and I was a pulmonary function technician. And our lab was always kind of slow. It was more of a research lab. And so when things were slow, I'd go on rounds with the doctors. And one day we were in the ICU and I remember watching one of the fellows intubate a patient. I said, that's what I want to do for my career. So I did this critical care PA program. And then there was a problem of finding a job because in 1979, 1980, it wasn't easy for PAs to find jobs, quite frankly. Most were going to primary care, those kinds of settings, general medicine. But thankfully I was involved in a Monday night basketball league. And one of my fellow players said, I had a temporary job. And he goes, you're pretty unhappy in what you're doing, right? And I said, yeah. Well, I heard about my father-in-law was looking for this guy. So make a long story short, I was hired by a 350 bed hospital in Columbus, Georgia. I ran a department called critical care monitoring. And I was in charge of putting in all the central lines. And I was hired by a hospital to put in all the central lines in the hospital. And I maintained the lines and I did all kinds of things technically. And, you know, the cardiology, cardiologists had some reservations about me doing this new procedure called the Swan-Gans catheter. Not pulmonary artery catheter at that point, it was the Swan-Gans catheter. This boy do it, are we sure? I don't know. Well, long story short, when they found out I'd come back in from home at 2.30 in the morning, put a swan in, get the hemodynamic profile and send them all that stuff. Hey boy, you got it, you got it. So they were quite generous and would send me to medical conferences and such. I kind of outgrew that job and I went to work for some private practice for some cardiothoracic surgeons, which I'm not really a surgical personality. And so I had some issues, but I loved working in that cardiothoracic ICU. And so when Emory gave me a call, former classmate gave me a call, said, hey, I just quit, you wanna come up? I said, sure. He always teased me, he said, you know, probably knew you wanted to come. I think you had the U-Haul packed before I hung up the phone. So I really did wanna get out of there and I've been in Emory the majority of my career there. So I did cardiothoracic ICU. Eventually, well, starting in 1980, I joined the Society of Critical Care and started coming to the meetings, not really involved, potentially, but I would come. So I did the Emory thing in cardiothoracic, I did some teaching and that sort of thing. But fast forward to the last six years of my career. Some of you know Tim Buckman. Tim Buckman came to Emory to organize our ICU situation. He and I hit it off pretty well. And he said, look, Rob, I want you to organize a residency program. I said, for whom? And he goes, nurse practitioners and PAs, you know, but PA, you know, they all need critical care experience. And we want you to establish that. And there was a nurse practitioner, Heather Myson, that worked with me and we built that program. It was a wonderful program. When I wasn't completely terrified, I really enjoyed doing it. But we did that and following my retirement, most of those programs that are created, we call them either residencies or fellowships, depending upon what institution you're in. There was a way to accredit the nursing portion of that. That was established, but there was no way of accrediting the PA. It just didn't exist. So in retirement, volunteered my time. I spearheaded the effort to get the accreditation process for the PAs. So that exists now. I think there are 12 to 14 programs that in the last five years that have been accredited. So that was very rewarding. I've continued my involvement with the Society of Critical Care. I wondered what kind of institutions I'd be involved with following retirement. My brother is a Rotarian, so I kind of looked into that, but it wasn't a good fit. And as I looked on the society, I said, these are my people. These are the people I want to be with. I know I'm not working clinically anymore. I don't know whether you use dobutamine with sepsis anymore or any of that kind of stuff, but I love the society and I wanted to continue and work with Judy and Steve when this was a, when we were building it. Task force. Task force, thank you. Task force. We got through that phase and then became a committee. So it's been a great experience. So overall, I would, although there have been ups and downs and some really tough times, I wouldn't change anything in my career. I will say in the same vein as Judy and Steve that I had a lot of support. My wife is a nurse. She was very understanding. I remember when I was in private practice and just working all the time, the call schedule was easy because you just worked all the time. I remember I hadn't seen my kids in about three or four days. And so she, I was, this is about seven o'clock at night. I had some critically ill cardiac guy. So she called me and she said, we're coming to the hospital to see you. We're going to have dinner with you. So we're going to cut out some time, we're coming. So she came and we had these round tables in the doctor's lounge. She literally brought a red and white checkered tablecloth. She put it over the top. And we had this awesome picnic with my two girls and my wife. So it's things like that, that infuse even through hard times, keep you going. I think looking at, there's so many things we're going to say and I want to leave time for questions, but I think overall, it's been a fabulous career. Like I said, I wouldn't have it any other way. And I am encouraged as I kind of wonder how long I'll be part of this society, but I look at you, what you're doing and it's exciting to come. It's really exciting to come and see what you're doing. So thank you. So I think I'm going to take the privilege of being the moderator and ask the first question. So it's sort of a two part question. What drew you guys into critical care and what is your advice for keeping it fresh or staying engaged with the bedside care throughout your career? Let's start with Judy. So my very first clinical rotation as a doctor of pharmacy student was in an ICU and it wasn't by choice, it was, here's your schedule and there you go. And one of our fathers of critical care pharmacy, Dave Angerin was my preceptor. and literally on the very first day, he said, have you ever seen a patient die? And I had not. And he said, go to that bedside, that patient is dying. And he didn't die that day, but was incredibly critically ill. And watching how the team managed to balance a complex situation with incredible humanity. And actually that, interestingly, it was a cardiac surgery rotation. So that's a funny, I bookend, I hadn't thought of that. I bookended my career in cardiothoracic surgery. But it just was so inspiring. And then, you know, the rest of the activities were so inspiring and interesting. And so I found my pharmacy personality right off the bat. And, you know, I could no more sit in an office or do drug information than anything else. But I needed that environment. And so I identified it quickly. And, you know, every day is a new day. And so there's something new to challenge you every day. So that's what got me in there. Yeah, I was drawn to critical care probably during my chief residency in internal medicine, because I was attending, I had to be at the ICU conferences and there was a senior, wasn't really trained in critical care, but he was very fascinated about hemodynamic monitoring and metabolic support. And this was an era when, you know, we were placing pulmonary artery cateters or swan gans cateters right and left on patients. And I was just fascinated by the physiology of respiratory failure and mechanical ventilation. And I thought a good way to get into critical care was through pulmonary medicine. And so that's what I did. Pulmonary critical care at NYU. And then I did another extra year of surgical critical care at Mount Sinai where I ran into the late Tom Iberti, who was running a sepsis trial at the time, the E5 for those of you who might remember the anti-endotoxin trials of the early mid 90s. So I was fascinated by that. And then I moved to Montefiore where I had the privilege of working under the late Vlad Kevetan. I don't know if you know Dr. Kevetan was a pioneer innovator. He was probably the godfather of disaster medicine. And Vlad really taught me the importance of organized critical care, integrated critical care. You can't have disparate units and siloed units and departments and that you have to bring them all under one umbrella. So it would take me many years to learn those lessons. Then I found really my calling at Sloan Kettering where I've been for 20 plus years. And that was to me, I guess, where I, besides my involvement in critical care in the society, I really got my footing in terms of thinking as a, not only as a clinician, as a researcher, as an administrator, as a teacher, getting involved in all of these clinical trials. And that continues to be my passion is trying to find new therapies, trying to establish new educational strategies to teach our young fellows, residents, nurses and nurse practitioners and PAs. So I love the interdisciplinary nature. And it really is in the last, I would say 30 years that I finally understood the true meaning of critical care. And that's really a team effort. And you have to bring all the themes together. And so that's what I've been trying to push. And integration of critical care really has been also driving me to continue. Is there so few of us that have service lines in critical care? Emory has it, Mayo, Cleveland Clinic, but it's only in the major academic centers. And so I've always been trying to push that sort of like agenda of mine to try to let folks know and administrators know about the importance of bringing ICUs together and having more centralized governance of critical care. Yeah, both of you have mentioned change as keeping you fresh in the same way. A little different area, a little less sophisticated. I've been reflecting a lot on this topic as I was preparing for it. Medicine has changed so much since 1980. 1980, it was still sort of a homegrown thing and you get away with a lot. We didn't know any better. But I think just the challenge of critical care, I shared with you how I became interested, but it was just kind of a growing fire, as it were, within me. I think one of the things that really excited me was the publishing of my first article. So a little survey here. How many of you have ever heard of the journal Resident and Staff Physician? Any takers? Very rare. There's one. There you go. So Resident and Staff Physician was a freebie you got in your mailbox. And I'm not sure, I don't think it was peer-reviewed or anything like that, was it? I don't remember. Anyway, but it was an interesting journal in that although it didn't have the sophistication of the New England Journal or some of the others, everybody clung to it. Because as a newbie, it had articles in there, say, five tips for successful chest tube placement. That kind of stuff. Nitty gritty, how do I do this at 2.30 in the morning kind of stuff. So my article in there was a hemodynamic profile with the use of the swine gans catheter. And it's an article that I wrote because I didn't fully understand what all these parameters were, from cardiac index to systemic vascular resistance, pulmonary vascular resistance, and all this other kind of stuff. So I initially wrote it for our house staff. We had a family practice house staff in that hospital I described in Columbus, Georgia. So they could understand it. And then one of the attendings got a hold of it and said, hey, boy, you need to publish this. So I did. And we wanted to publish it in an area where I could get the greatest exposure. And so we chose resident staff position. So that kind of refreshment was good. I think when I moved to Emory, that was another shot in the arm. Just being, moving away from the family practice oriented hospital to an academic institution, I found that quite stimulating. From everything from learning more about intensive care medicine to establishing collegial friends. And that was a wonderful experience. And I, you know, in terms of just keeping it fresh, I shared with you what my wife did to help me. I think, and particularly, so I am a pre-COVID PA. I did not go through COVID. I had it, but I didn't go through COVID. And that really changed the face of intensive care and medicine in general. But looking back on it, I really looked for little things to help keep me refreshed. And this is really gonna date me, but just allow me. And those intense times when I was there and we had patients that were sick, sick, sick, and I just felt like the whole world was gaving in. On the way home, I'd stop by the mall. And I had a particular bench in the mall where I would sit. I wouldn't shop, I wouldn't do anything else. I'd go right to the bench. And it was in between a shoe store and Old Navy. This is not a plug for Old Navy. I don't have any connection. But I would watch the little children come out of the shoe store with that new pair of athletic shoes bouncing because they could now run faster, right, in new shoes. And I'd watch the teenage girls come out of the Old Navy with the new outfits talking about their boyfriends. And the conclusion there is not everybody needs critical care. Because when you're inundated in that environment, it's easy to get down and think the whole world is sick. So it was just some easy things. And there's some other things. Amazing. I think at this point, I wanna open it up to all you guys for questions. If you don't mind stepping up to the microphone so we can all hear. Congratulations, all three of you, such illustrious careers and thank you for what you did. So I have two questions. One is, I'm sure the words burnout and psychological safety weren't buzzwords at all at the time of your careers. Whereas now you see even into the careers of three to five years or six years, people start getting burned out. So what is the huge difference? What happened that we are less resilient than before? My second question is, how do you really balance now being here with these questions of psychological safety, how do you balance that with accountability and competency? Thank you. Tough question. You know, it's interesting. Could you say that I retired because I was burned out? I wouldn't say that. I just recognize that the hours were not gonna be compatible with the way I wanted to live my life at that point. And, but I've had conversations, oh gosh, internally and with myself and with colleagues over all the years. So I think part of it is that we just have a name for burnout. So I think it's given some structure because it's always been there and have known far too many professional colleagues who've committed suicide. And, you know, it really wasn't talked about. And so I'm, you know, it's been there. And so maybe part of it is that we're just willing to talk about it and try and learn about it and see what we can do to help prevent it. Honestly, SCCM was my way to prevent burnout in sports and, you know, athletics. But everybody else has given their spouse credit. My husband's a pharmacist and ran the Statewide Poison Center in Indiana. And so was very involved professionally as well. But he was the one who, you know, at times would be the one who would set some limits and he never brought dinner with a little tablecloth. But, you know, that kind of voice of reason saying, hey, you know, there are other things in the world and you're working too much or volunteering too much and so for me saying no was something that he helped me be a little better at. So I'd be curious the other's perception in terms of burnout and, you know, maybe part of it's generational because I'm clearly in that baby boomer group and a lot of my physician colleagues are all the same age. And so you just put your head down and worked harder, you know, and so that may be the other factor is that it's always been there but nobody's really been willing to confront it and deal with it as directly. Yeah, I concur with Judy's assessment. I mean, we all experience, you know, burnout symptoms in science, even way back in training and early and mid-career. I think it was always there but decisions are trained just like in the military that, you know, there's a hierarchy of structure and so you just have to suck it up. You know, when I was in training, there were no such thing at work hours. And so, you know, there were days in a row when we had calls where I didn't see my little kids as well. So you kind of at that time had to go through it. Maybe we just referred to it as, you know, stress, healthy stress that you just needed to, it was part of becoming, you know, a full-fledged doctor. It was just part of training to become a specialist. But I think it was always there. We're recognizing it more. We're speaking more about it. And then with the rush of decision suicides and other healthcare practitioners suicide, I think it's even coming up to the core four. And now with COVID, hopefully behind us, hopefully never to come back in the way it did. I think it's causing more grief to a lot of folks. But, and so you just have to adjust when it comes along and know how to handle it. And I think that's key. I don't think that the anti-science movement has helped anybody either. You know, if you feel like somebody's already always second guessing you when, you know, you're already in a stressful situation, it can't be helpful. I agree with everything that's been said here. I think one of the things, and I'm of the same age, so you did just put your head down and work harder. Part of mine, and Judy, you may have faced some of this too, is in the early days, they wanted to know who you are and what you're doing here and how you could contribute, right? Oh, yeah. And it persisted for some time and it gets to be just competition, you won't beat me. And so I just pushed on through it. And, you know, thankfully my wife supported me in that. As I look at burnout and a lot of things, and so much has been published on this and we have whole seminars on it, that's not the purpose of this meeting. But sort of philosophically reflecting on it, there has been generational changes, as Sergio pointed out earlier. I'm very concerned about what I see in our young practitioners where it seems like a lot is self-centered. And I think a lot of it has to do with electronics and if not computers, then your cell phone and always being on that. And I think it's very hard to stay fresh when you're constantly bombarded with little things. And so I was reading something online and unfortunately I can't remember where it was, but it said, it's not the long vacations that you take to Iceland, for instance, we saw earlier, but it's the small moments in between that you take to refresh yourself. When you turn off the phone, you take a deep breath and then you get back to business. So if I had to encourage you in one way, it would be that. Honestly, I'm like you, I'm connected to my cell phone. Now it's with grandkids and other stuff. But I think it's imperative that we all take mental breaks fairly frequently of three, four, five minutes and just go into some place where you can't be. The linen closet at the hospital or some place where they can't find you for about three minutes and be refreshed. I think though it's, one perspective, as Sergio did so well today, kind of pointing out perspective is everything. And so I think it's refreshing and important and valuable that work-life balance and healthy lifestyles are a bigger focus. Because honestly, if we're as providers taking better care of ourselves, then I think we have the potential to take better care of our patients as well and support our colleagues and perhaps be more in touch with the needs of our colleagues. When you were pushed to the limits every single day, it's hard to have bandwidth for the folks around you. And so hopefully that's a value that's coming out of it and recognition that it's not one person killing themselves. And as we've learned, it's not even our whole team killing themselves. You get some support there if you're all there together. But it's finding a way to do that in a way that's much more healthy, I think. And I don't remember your second question. So then we had the burnout question. What was the other one? Do you want to ask it again? Okay. I think we have time for one more question. Someone has something in the audience. So, thank you for sharing your stories and your trajectories. It's really actually very inspiring to hear what you guys have all accomplished. I'm curious, kind of based on what you guys were just saying, what advice would you give your early and mid-career selves in this part of your career? I'm going to have to go first. So just to kind of paint a picture, when I joined the Society of Critical Care Medicine in 1982, there were very few pharmacists. There was, you know, certainly under 20. And SCCM, being founded on a multi-professional organization, wanted every team member virtually in every committee task force guideline. And so I got incredible opportunities to interact with people who, like myself, became leaders in the organization, and we all just were starting out as newbies. And so I think probably the most important advice for anybody who has a situation where they come in and somebody has said, gosh, we're really glad you're here. Can you help us with this? To embrace that opportunity and just do your best with it. It's never going to be perfect. Sometimes you get stuff done and it's done, and it's never perfect, but embrace those opportunities because it can lead to very fulfilling things in your life. And as I said earlier, just, you know, mid-career, I continued to look for those networks, connections, opportunities in the organization and elsewhere in my life to, you know, kind of bolster and expand the things that I was able to do and interested in doing, and that's what kept me going as well. Sometimes you have to kind of insert yourself a little bit to get those opportunities, so don't be afraid to take that opportunity. And you know, if you want to volunteer for a committee in SCCM, be a little braggadocious about yourself. You know, don't just say you're interested saying, you know, I'm interested and here's what I've done or what I bring to the table to contribute. So don't be afraid to push yourself into those opportunities and look for the chance to take them. For those who are in more like the academic world, I think early on, you have to like find a mentor. I was blessed with having several mentors in my early days as a young critical care doctor, so that's key. If you're into research and you have a passion for clinical trials, again, having a good mentor is important, and certainly networking with colleagues who may have the same interest. The society has given me that opportunity as well to get involved in clinical trials. So you just have to find a good network of folks that can help you, whatever your passion is, be it teaching, research, clinical trials. I mean, these are all things that you should think of pursuing. And then early on, a lot of the times in the first 10 years or so, we're a bit more self-centered, you know, we want to advance, we want to go from assistant to associate prof in five to seven years, we want to be associate in seven to 10 years, we want to be a full professor by year 15. And so in the first 10, 15 years, there's just this big push. Sometimes self-centered, you're just focusing on, you know, writing that next paper, you know, publishing in New England Journal or something. And that's fine early on, but I think you just have to, at some point along the way, you know, find time to not get too pressured or stressed. And then as you get into that mid-portion, you know, you don't take too much on your plate, you know. Many things are, you know, maybe in the beginning, you know, you can do all of these things. Maybe not as good as you might think you are, but I think at the midpoint, you should start saying no to certain things and only do the things you really want to do. And what you think you'll be successful, you know, whether it's a specific committee of SCCM or clinical council or P&T committee at your institution, if you have a special interest in those areas, just focus on those, don't just take on too many things on your plate. So I think that's key as you approach that mid-career and just focus on how you accelerate your academic promotion by just narrowing your interest to maybe two or three and really excel at them and don't just be a jack-of-all-trades, but a master of none, I think would be an important message. Well as intensivists, you're all concerned of properly ventilating the patient, right? You want to make sure that everything's perfect there. I think if we take the term ventilation, kind of in a wide sense, I think it applies to early, mid, and late career. So actually when I was thinking about this, I did a little acronym because I like acronyms. So it's AIR, A-I-R, okay, A, aspirations. Early in your career, you aspire to make a difference. You're there to help people, but you want to be known, and that's okay, but it's deeper than that, and I think you need to consider that in early and mid-career where it's not just about you, it's about who you leave behind you. So certainly well-treated patients, but also colleagues that you're bringing through. So when you think about your legacy, even early on, it's kind of like buying life insurance. You're 25, you don't think you need life insurance, but it'll pay off in the end if you do. But anyway, think about your legacy in terms of not just being admired, but being imitated. And what kind of building blocks in year five, year 10, year 15, 25 am I going to lay down so I can have that? One letter, I, intent. We all aspire to be great leaders. That's one of the reasons you pay the extra money to come to this seminar. But I caution you, whether you're early, mid, or late career, to work for the greater good. It's not just about you, it's about the whole thing. You have skills and gifts to help patients, and hopefully you'll work with integrity. And by the way, integrity is not just one thing, it's a matter of small battles. Everybody thinks that if you win one big battle, you'll have integrity, and it's fighting the mundane battles every day, the daily skirmishes in your life. If it's done with integrity, you'll have those building blocks I talked about earlier. And finally, reflection. And you need to reflect as a junior, as a mid-level, and a senior, a clinician. Self-assessment is absolutely necessary. Ask yourself two questions. One, do I do everything with integrity? And two, have I done the best that I could possibly do every day? I think with those in mind, if you start that early in your career, even through your mid-career, you'll be very successful at the end. Thank you for those very thoughtful pearls. Unfortunately, yeah, we are at time for this, but there's going to be a lot of opportunities to talk to Judy, Rob, and Steve after this. Let's give another round of applause. I'm going to invite Josh up for our last session. I like that, air. All right. So, we have about 20-25 minutes left for the session today. They seem to have put me at the beginning and the end. I suspect it's so that when you're evaluating the course, you'd be like, man, the middle part was really good. So, we're going to circle back to something we talked about at the beginning on moral injury. I don't know if anybody had a chance to watch the lecture I did for this course last year. We didn't include the lecture for this part for this year because we wanted to give you all more time to interact with each other. I think it was the right thing to do, but it's something that we're all going to face. If we haven't already, and your teams are going to face it, and as leaders, it'll be important for you to figure out mechanisms to be able to manage moral injuries so that you have a healthy team that can do good care. So, we intentionally put this at the end to give your groups an opportunity to work together, to get to know each other, develop some comfort with each other. So, what we're going to do now is a little bit of sharing out just at your tables and your small groups. I had a slide deck. Sir, I had a slide deck on moral injury. No, no problem. So, I think one of the keys to managing moral distress is very much. Kaiser, Josh Kaiser, K-A-Y-S-E-R. One of the keys to managing moral distress is talking about it. I think that the more we talk about it, the more we're able to come together in a collaborative way and recognize that we are all feeling the same thing. It really helps us to normalize it, validate each other's emotions, and provide for support for each other. So, in a moment, this whole 30-minute, 25-minute session is really only just you all sharing in your small groups. There's no sharing out, there's no microphones. Certainly, I can answer some questions at the end if we have time, but it's really meant to be a tabletop exercise only. Kind of finish things off. I do promise there will be adult bevies to follow. So, if you really share out some heavy moments and really go ahead and express that vulnerability, you'll be rewarded on the back end. I'm not saying that going out for a drink at the end of a hard day is the solution to moral injury, but it certainly helps. So, you know, there's that. How are we doing? Any luck? That's okay. K-A-Y-S-E-R. Maybe, I don't know if Dawn's around. You got it? Fine. Thank you. Yes. No blame here. Thank you for your efforts. Okay, so for those of you who didn't look at the slides or looked at it but forgot, I just wanna offer you a definition. Moral injury is the inability to act according to an individual's ethical beliefs. So your strong belief that you need to act in a certain way and you feel that something is preventing you from doing that. So here's what we're gonna do. We're not gonna have a full 30 minutes because we do wanna finish on time. We have 20 minutes. So let's just pare this down to, oh, I don't know, six and 14, something like that. So first I want you to do is at your tables, just kind of pare off into pairs or if you don't have an even number, you have an odd number, you can do a trio and share an experience with your partner or partners where you experienced moral injury related to ICU care. Consider the following. What emotions did you experience? Emotions. What existing barriers resulted in this situation and was there any resolution at the end? So go ahead and pare off at your tables and just pare and share. Sounds like there's a lot of good work being done. Some of the tables went rogue and all shared in the communal space. I feel like that's what we were gonna do then. I'm gonna give props to the tables that actually pared off. There was a method to my madness because if everyone pairs off, everyone gets a chance to share. But I hope everybody got an opportunity to speak a little bit and share some of the experiences that you've had. So now at your entire table, we're going to rejoin our full small group at the table and we're gonna go through over the next 14 minutes, we're gonna go through these last four questions. I'm gonna let you manage your own time. The questions are up there for you, but emotions result in behaviors. So as a group, brainstorm some types of behaviors you have either personally experienced or witnessed resulting from moral injury. Second is question three, discuss the differences between individual and institutional actions. What individual actions have you taken to reduce moral injury and enhance your wellness? Why might institutional actions be so important to combating moral injury? Number four, what if any actions have your organizations taken to address moral injury? And then last, number five, organizations, particularly large ones, change slowly. What strategies can we as ICU leaders use to implement small changes to improve microculture and team satisfaction more rapidly? All right, how about it? I hate to break you up from your outstanding conversations. I was walking around and just kind of listening in at each table. And it really felt like you guys were having really thoughtful, intelligent, helpful conversations. I hope it was valuable to you. The method behind this is really that you are the best person to solve your own issues in your own institutions. And you're gonna learn a lot more by talking to each other and hearing from each other and sharing ideas and brainstorming than if I stand up here and give you a big lecture. However, if you really wanna watch the didactic that I gave last year, it is recorded and is available to you in the materials that you are offered. And it does include a number of different types of exercises that you can employ at your local institutions, whether it's grieving rounds, sessions, or how to run a debrief, a real-time debrief, or medical humanities rounds where people bring in literature or music or poetry or anything that connects us as humans to each other, a pause ceremony when someone dies in the hospital, in the ICU. These are all a bunch of different techniques that have been developed at our institution and other institutions to help us support each other. But the most important thing you can do is really just share and talk about it. I will finish with one last question, but you don't have to answer this one. I just want you to think about it. What are you gonna do in the next 24 hours to cultivate joy? Because that's really, in the end, what gives us, maybe it's the bevies that are coming. I'm gonna have a drink. What else, besides the beverages, are you gonna do to cultivate joy? Because that's really what gives us the resilience to continue to do what we do. Thank you so much for your time. Really enjoyed working with you today. Thank you.

Critical care longevity

Career experiences

Mentorship

Work-life balance

Burnout prevention

Self-care strategies

Teamwork in critical care

Moral injury

Resilience in critical care