Hello, and welcome to the 51st Critical Care Congress. My name is Sigrid Burris, and I am at the Loma Linda University Medical Center and in the Surgical Intensive Care Unit there. For the next bit, we'll be speaking about emotional resilience during difficult patient case scenarios. Expectations for us are quite high. We are expected to provide compassion to our patients and their families, error-free in our assessments and implementation of plans. We also have to put aside our own physical and emotional constraints as we take care of these critically ill patients and work within systemic challenges and organizational demands. Sometimes it certainly feels like we need to sacrifice everything. Recently, we had a patient that came in after a pedestrian versus auto accident that had resulted in a severe traumatic brain injury with a subsequent GCS of three. Unfortunately, over the course of the next few days, despite supportive care and appropriate interventions, he did progress to brain death. He was evaluated by two different practitioners and was pronounced brain dead. The family was obviously very distraught and sad, but in addition, they were very angry, really not believing in the diagnosis of brain death, and blamed the physicians and nurses for not providing appropriate care and that we had wanted this to occur. They were very disruptive, very accusatory, and really made the whole environment unpleasant and toxic to be in. Although this eventually was addressed, the whole situation was very disheartening to all of us that took care of the patient, because in our minds, we really had done everything that we could to support him and try to get the patient through this, although we were obviously unsuccessful. That's what makes these so challenging, is that we really are trying to help our patients and their families, and sometimes it doesn't work. We operate within the constraints of medicine, and when we do everything that's absolutely possible and still have a bad outcome, it's not only aggravating and frustrating for the family, but for us as well. We all take our profession very seriously as we do the well-being of our patients. That kind of challenge, day in and day out, can really take a toll on us. As Dr. Darrell Kirsch from 2014 AAMC keynote address said, we need to maintain our connection to our mission by strengthening and securing our support networks, so that when we come up against challenges, we do not face them in isolation, but rather feel part of a mutually supportive group of colleagues with a shared commitment to epitomize resilience, and we will continue to thrive if we affirm our shared mission, reach out empathetically to one another, and rise together to meet the challenges ahead. That is certainly easier said than done. So what is burnout? We may have all experienced this to some degree, especially over the past two years, but it's that feeling of emotional exhaustion, the depersonalization, and the perception of low personal accomplishments, and when those are really taken to heart and persist in our minds, we also end up being less productive. We take more sick leave. We may even change our current job or leave medicine altogether. We are more likely to make medical errors and also report providing suboptimal care to our patients. Some would say the answer to this is resilience, which is derived from the word to lead back or recoil. The definition of the Oxford Dictionary is the ability of people or things to recover quickly after something unpleasant, such as shock or injury, has occurred. Teaching resilience and addressing burnout are certainly hot spots for our ICUs and medicine in general, but even when we look at the data and things that we can do to improve our resilience and decrease burnout, physicians sometimes are very resistant to these interventions. And why is that? Sometimes those things that we implement in hopes to mitigate burnout actually end up backfiring and really end up aggravating or frustrating the providers even more. So then the question is, is burnout an individual or a systems level problem? All of us went into medicine to become caring and compassionate providers of care, and medicine unfortunately is sometimes moving away from that as it focuses on flow capacity, being able to discharge patients in a timely manner, making sure throughput is good, looking at budgetary constraints and staying within those, which sometimes means not getting the staffing or equipment that we may want or need to provide care for our patients. And we also have targets that we consistently need to meet in terms of having mandates that are attained and that can provide challenges as we, again, move away further and further from the patient and from the bedside. Sometimes too, we focus too much on what we can bring to the organization, whether it's prestige in terms of volume of publications, the amount of work that we could do, the number of calls we can take, or just the sheer number of volume that we can do in terms of our views that we bring in. Again, not representative of the care that we provide and the time that we spend with the patients at the bedside. Looking at mental health in our health care providers, especially during COVID, there are some significant concerns as we see job stressors and fear for our own health and well-being being key in terms of affecting or increasing the odds of developing depression, anxiety, sleep disturbances, post-traumatic stress, burnout, and overall lower resilience. In Belgium, they looked at the role of resilience in health care workers and found that those that measured as more resilient demonstrated less distress during the COVID-19 pandemic. So again, that brings us back to resilience. How do we get there? What is it? So Roslyn et al. performed a metasynthesis of all the qualitative studies looking at resilience and came up with six themes of resilience, which are tenacity, resources, reflective ability, coping skills, control, and growth. And if you reflect back on the initial case that I presented, all of those skills and all those themes come into play when we deal with angry, frustrated patients and families, and sometimes even our own frustration for not having been able to do more for our patients. So when looking at the original themes that allowed them to develop the final themes for tenacity, it really highlights pride in our work, the personal meaning of our work, our own aspirations and values, the empathy that we give to patients and ourselves and our colleagues, as well as our connection with patients and the work, as well as the support that we receive from friends, family, colleagues, and others as a whole. Secondly, when we look at resources, we do need support in order to do the work that we do and to do it well. And that comes from our personal support systems with family or friends and community, as well as with our colleagues and having an atmosphere of teamwork and collaboration with trust and respect among providers. And within the institution, the resources that we need and the organizational support in order to do right by our patients. Next, we look at control, because within that, we need to be able to be self-aware and acknowledge our own limitations, as well as when we need help, whether that's with mental health care or just being aware of our own basic needs and prioritizing those, especially sleep. And within our professional boundaries, that control also is going to include the ability to have a locus of control, to have personal boundaries set up and professional boundaries as well. We also think about coping as one of the pillars of resilience, and that is the ability to speak about job-related stress and to do so in an open, confidential, empathetic manner. And to recognize when change is necessary, when the system that we're working in doesn't work, to be able to speak up and make adjustments as needed. When we look at our reflective ability, again, having our own goals in mind of what we need and how to achieve that, and being self-aware and developing a good appreciation for what is working well. And then lastly, growth, that allows us to be always moving forward within our own profession, developing new skills, as we often need to be flexible and adaptable, which again, especially during this time with COVID, we've all had to do significantly, working sometimes outside of our usual environments with different staff. And for myself, in the surgical ICU, no longer taking care of surgical patients so much, but more medically ill patients. And this is put together in a conceptual model of physician resilience. We look at our work and that that should be a nurturing work environment that is supportive, both again, at work and at home, and that we collaborate and that we truly are team members and going through this together and supporting each other. Now, when we think about the different themes, there are different ways that we can approach and institute change. And some of it is a little bit easier to do as it's physician-directed and others might be more challenging or take a little bit more time to implement as they are organizationally directed interventions. So from a physician-directed perspective, when we think about tenacity, we can educate ourselves on mindfulness and learn more about that to develop our own skills and resilience. We can also think about what specialties we're in and what changes need to be made. And when it comes to organizationally directed interventions, thinking about that patient interaction and optimizing the interactions that we have with them, not just running through the day and checking boxes, but really spending time with our patients to get to know them and their families. We look at resources, training to improve team communication, as well as conflict resolution is key and is something that we all can implement. And from a more organizational intervention, thinking about our duty hours, our on-call, making the hospital a little bit easier in the sense of having call rooms, our own space to rest and reflect, potentially having additional staff to reduce the clerical burdens as we all have more than enough paperwork to do. When it comes to control, we can educate ourselves in how to break bad news, doing grief counseling, especially in the ICU with all of the family members and patients that are truly ill and may not get better, to be able to engage in a meaningful conversation with patients and families about goals of care and end of life. And then from an organizational level, again, thinking about flexible work schedules, part-time even, if that is what we need to have better control over work and home life, having access to mental health care services, and also understanding what the leave policies are for where we work in terms of medical or parental leaves without having to worry about whether a job will be safe and secure when we return. Next, coping, coping skills, training and stress management are certainly essential, but even with that on the organizational level, really reducing that unnecessary bureaucracy and thinking about what we can offer, and that may include better meeting plannings, making sure that they're well organized and that the goals that are set out for the meeting are attained. And the ability to reflect as well, and again, especially mindfulness training or reflective skills training to allow us to think back at the occurrences that have happened throughout the day, whether that's interactions with patients, families, or even our colleagues. And that can include on an organizational level, regular debriefing sessions. So especially when we think about codes, or other things that occur that could have occurred differently, and not necessarily have had a different outcome. But certainly our interactions and how we communicate with one another need reflection on and that debriefing session allows us to communicate both within the physicians with nursing and all the other ancillary staff as well. And then growth, so that we have the ability to participate in mentoring or coaching programs, receive feedback, but constructive feedback that is meant to support and educate and improve all of us. And it's not just simple criticism. So when we think about mindfulness, it certainly is one component to addressing burnout in medicine. It may not impact the culture that we're working in, or the efficiency of our practices or the organizational environment. But it can improve our own personal resilience and allow us, especially in challenging times, such as we've seen since the start of COVID, to have a little bit more room for maintaining good interactions with patients and families and colleagues, and maintaining our own well-being. As Jon Kabat-Zinn would say, mindfulness is awareness that arises through paying attention on purpose, and the present moment, non-judgmentally. And as part of mindfulness, as we sit down and reflect for a minute, we're going to go through the components of gain, which are gratitude, acceptance, intention, and non-judgment. And again, especially as you think about a challenging patient encounter that you've had, or an encounter with a colleague, or just overall frustrations that you're currently experiencing, I want you to take this moment to reflect on that. And I want you to pause as we go through this process. There are no rules, and there's no special way to sit or to do this. But in general, I want you to take note of your body. I want you to relax as you're sitting here with the sensations and the connection with the floor and the chair. And just relax on any areas of tightness or tension. Relax those shoulders and just breathe in and out. You'll note the rise and the fall of your belly and your chest, and the relaxation of your body as you breathe. And as you come into a rhythm of breathing and letting go of that muscle tension, I want you to think about gratitude and what you're grateful for. And I am grateful for my health and my family's health, and fortunate to be connected to a community, both at home and at work, where I'm privileged to be part of this process, to engage with people who are ill, and to do my best to help them and alleviate their suffering. And now to transition to acceptance, where life is full of suffering, but it's also full of joy. And we need to embrace those moments. We all suffer, and we all have experiences that bring about sadness and pain. But we can be aware of that. We can be aware of those negative feelings. But instead of labeling them as negative, leave them without judgment and be a neutral witness. And just let it be, and simply accept it as it is. Next, to focus on your intention, that we have the strength and the ability to decide on what we think and the ability to decide on what we think and how we act. And that we can choose to be happy and choose to engage with others in a positive manner. And I want you to reflect back on three good things that happened yesterday, and to smile, and to keep this with you throughout the day. And next to turn to non-judgment, where instead of labeling things as good or bad, or worthwhile and useless, that we can observe that and say, I don't mind what happens, and to cherish that benevolent indifference. And that the world will keep on going, regardless of you naming or judging it. And now to return to your breath, to slowly hold it in and out. I hope that you feel good, and that you are now refreshed as your awareness of gratitude, acceptance, intention, and non-judgment are in your head and moving forward. I recently had a patient with metastatic cancer and associated paraplegia from spinal metastasis and cord compression who came to the ICU with sepsis. A CT scan of the abdomen pelvis done as part of the sepsis workup revealed free air from a colonic perforation. Prior to this hospital admission, she was already doing very poorly. She was on home oxygen, paraplegic, palliative chemotherapy, and also end-stage renal disease on hemodialysis. With this in mind, we discussed surgery with her, but she was unable to decide on what intervention she would want. We brought in the family and discussed options with them, but no one had ever discussed with her goals of care, not even her DNR or DNI status. These were all completely unfamiliar topics, but even though this patient had already been dealing with metastatic cancer for quite some time and over the past two months had declined significantly as a result of her metastatic cancer, no one had discussed goals of cares with her, and here we are having to make an urgent decision on whether to proceed with surgery or not and to start from scratch. You can imagine it being frustrating as without surgery, she would die, and even with surgery, there was a good possibility that she would die. We might extend her life, but at what quality and would she ever leave the hospital or the ICU? These discussions are very challenging and not just for us, but obviously also for the families and the patients. These are difficult discussions that we have on almost a daily basis, and although we are privileged to be a part of it, it certainly takes a toll on us emotionally. And during that height of COVID where we were doing these discussions multiple times throughout the day, there were many times before walking into the room that I and others had to take a deep breath, knowing that we had to have this conversation again and again. But trying to remember that for families and patients, this is a new discussion. And to be grateful that we're part of this process and that we may not always be able to save someone's life, but that we can always be a part of their life and alleviate their suffering in whatever the appropriate manner is. With that, returning back to resilience and being able to really engage with our patients, our families, and our colleagues, even during some very challenging times. I bring us back to this study, looking at Scrubs, one of the TV shows that reflects quite a bit more than some other TV shows of what medicine really is like. And this group looked at guided group discussions using Scrubs as the focus of that discussion. So after watching each of the episodes, they had an ongoing conversation about the episodes, really allowing people to communicate their own challenges with each other. And when they observed over the few months that they did this, they looked at personal accomplishment, emotional exhaustion, and depersonalization, and saw improvements in all three of these categories. So whether it's Scrubs or some other format of guided group discussion, where we can build a community, and we can have a conversation about what medicine really is like, or whether it's Scrubs or some other format of guided group discussion, where we can build a community and be in a trusted environment that we can communicate our challenges with one another. And will allow us to cooperate better and be able to not lose our empathy and be able to recenter us and approach each patient and their families with empathy and compassion. Thank you.

emotional resilience

healthcare providers

burnout

tenacity

mindfulness

communication