Hello, and welcome to SCCM's ICU Leadership Academy. Over the next two hours, you'll have the opportunity to hear from leaders in our profession, as they share with you their top five tips, tricks, pearls, or things they wish they knew earlier in their careers. I'm your moderator for today's session. My name is Dr. Kristin Mount. I'm a staff intensivist at Madigan Army Medical Center in Tacoma, Washington, and I'm also the critical care medicine consultant to the Army Surgeon General. I'll be joined today by panelists representing the multi-professional disciplines that comprise intensive care. Our plan for the session is for each panelist to give you a little bit about their background, about the position they're currently working in, and then what I've provided them is 15 minutes of time for prepared remarks to discuss with you the top five things that have helped them in their career, the things that they want to pass on to those coming up behind them, things that they wish they knew earlier on in their career, perhaps mistakes that they've made that they've learned from. We will have time for live question and answer, and I'll do my best to moderate the chat or comments function to make sure that I'm gathering those questions as well. What makes this session unique is your access to leaders in our field, your ability to mine their wealth of knowledge and experience, so please don't be shy. I am confident that all of us will be able to leave today's session with one or two new things to think about, to incorporate into our professional careers, and to work on in the future. And with that, let's introduce our first panelist. It's a pleasure to be with you guys today. I'm Dr. Jorge Hidalgo. I'm from Belize. I'm the head of the General ICU at CalHouston Memorial Hospital and also at Belize Healthcare Partners. And it's a great pleasure to be part of this 50th anniversary of the Society of Critical Care. In the following minutes, I will try to cover some of the leadership academy, especially from the point of view of the international perspectives. I don't have nothing to disclose. And then, just to start, the year of 2020 will be remembered as the year of the most significant global pandemics in the Spanish flu. Severe acute respiratory syndrome, the coronavirus SARS-CoV-2, gradually encompasses the globe. And it left a trail of destruction in its wake. Now, as you know, hundreds of thousands of direct lives, loss, millions of persons affected by the disease in different ways, potentially with long-term health consequences, disruption of travel and trade, and dislocation of communities and individual lives. Of course, leaders across the world are required to respond both to direct and also to the indirect effects of the crisis. With little time, or probably in some, especially at the beginning, no preparation to face a situation like the pandemic that we are dealing now. For leaders, this significant uncertainty exacerbates the challenges associated with the decision-making and requires a rapidly adaptive response, not usually associated with the leadership in more business as in usual times. In a leadership examples on frameworks and the crisis, especially for the military and emergency management sectors most of the time have some more preparation. However, a key challenge of a pandemic is that an effective management of a situation requires of a large scale human collective behavior. And sometimes it's difficult to control and is not granted. Of course, one of the important things in leadership is the trust. And the trust is an individual expectation or belief often in circumstances of a vulnerability that the action or motives of another person are honest, fair, and based on integrity. And what we expect is for some ethical principles. Trust can be a system organizational or at individual level. It can be inspired by confidence from past behaviors. However, it's also a dynamic process. Most of the time trust also allows person with less knowledge, power, or ability to process complex information to rely on another individual or institution essentially to make the best, better quality of decision for patients. Now, as well as we can see that this pandemic now that we have the so-called COVID-19 infodemic or social media has essentially disrupted the key task of crisis leadership. We essentially are faced with a huge amount of a tsunami of different type of information. Most of the time information that is not based evidence and different type of information in a different level of a social media that people trying to absorb and digest in a rapid manner as the pandemia is evolving. And also as our lives are the lives of the people they feel threatened and they want to do something or they want to have something to rely. Nevertheless, in a pandemic, scientific and public health expert remain more trusted by the public than the non-health leaders. Now, the trust, confidence, and cooperation is important. We need to rely and we need to trust in the different authorities we have and also the different information that we can have from our different leaders. However, public trust in governments, leader and business has been declined over recent decades without trust in the leading organization, support for policy implementation is difficult to achieve, particularly in a short-term periods. Meaning that it's important that we can, as a leader trying to generate that trust. Knowing that trust is the key foundation of our relation oriented leadership frameworks, including situational leaderships, authentic leadership in servant leadership with transformational leadership also relying on a leader and a follower value a congruence. In this paper is important because as you can see is a complete review of the different aspects of how the trust, it can be achieved and how we as a leader can influence the behavior of the people that are essentially on our watch. We can say like that. Mean that one of the most important as a leader is that we need to be able to be prepared and plan for the last two decades. We have been provided glimpses into what the world is no experience like the H5N1 avian influenza in 1997 in Hong Kong, the SARS in 2002 and 2003, the 2009 influenza pandemic, the MERS in the Middle East and the Ebola most recently. Those things are basically give the countries a significant experience related with those previous outbreaks as how to more easily can handle it while we are dealing right now with the COVID-19 pandemic. And of course, it make the population to response in a more rapid manner. Without a specific, a large scale pandemic experience, however, leadership can be still prepared and proactive. But any planning, of course, can learn much from these previous experiences. And as we know or mentioned that, especially with the vaccines, we know that the experience of the SARS and the experience with the MERS and the Ebola, it help us, especially the scientists to develop more rapidly the vaccines. I mean, that also it is important that we can have a supported everything with information and data. Leaders at times of significant uncertainty should constantly seek for relevant information regarding crisis course, the impact from reliable sources that includes from health professionals, researchers, managers, industries, related sectors, but also from shared stories and experience from international colleagues, networks of collaboration, partners, that it will help us as how to approach in a certain circumstances and a certain crisis. The surveillance system, including a testing and contact tracing are crucial to understand the local scope and also the spread of the pandemia. A clinical data collection within the health system is equally important to understand local requirements for health resources, the patterns of disease and care, and what intervention and providing the best resources. An example is the different database like the SPRINT study in Australia that is collecting for acute respiratory system. The database collection for COVID-19 patients like for different stories from the World Health Organization and from different other organizations that are trying to develop. International information sharing and a global surveillance through research institutes like Johns Hopkins in the US provide with a globally transparent and aggregated real-time incidents and outcome data. Those are predicting data models that can leverage this provide leaders with a range of scenarios based on a specific assumptions of health guidance decision-making processes. Of course, we also need to be able to be adaptable and coordinated in a complex and unpredictable situations. Leadership must be adapted to it at all levels. Clinicians and researchers have constantly updated and adapted their definitions of understandings of the clinical course of management of COVID-19 that is really, really evolving. In order to build trust and the confidence of followers, leaders needs to make decisions and provide sense of control. Local command centers of other task-oriented leadership structures are critical in support of the intelligence gathering on timely decision-making. Also, we need to see leaders that we must remain connected with the communities that we lead through all this process to be informed of those core phases as well as to receive feedback critical to a decision-making. New things within existing structure may need to be created and conduits development and a lot of ways interaction with the frontline emerging and decentralized leadership should also be encouraged within an overall shared strategy. Leaders are responsible for the coordination of response including beyond the health sector, across public, private sector, non-governmental organization. This collaboration be hastily created by the form of crucial network or relationship alliances on horizontal coordination mechanisms. The greater the communication and coordination, the more resilience are the systems in the face of adversity. Either most engaged with the communities through a local groups to ensure there is a local ownership on that intervention are appropriate and acceptable. Communication is critical for that coordination to happen on an alignment with the leadership planning and goals as well as coordinating the response. Leaders must also coordinate initiatives to support the wellbeing of the followers including mental health supporter, staff and community welfare. And of course, we need to act with responsibility. Quizzes require leaders to take responsibility and to this by visible. By being visible and responsible, they are showing accountability that is really critical in the leadership and sharing risk with the followers an important sign of solidarity with the many health workers and others who face personal risk during the pandemic. Being responsible, they show a model of personal vulnerability and take it responsibility. That way we can face everything and also have the resilience needed to adapt. For followers to trust the leaders, they need to access objective information, open and transparent. That includes being that as a leader, we need to be accessible, available, open and willing to answer questions. It has rightly been said that during the pandemic is not time to identify some of the failings by the leaders. Mean that we need to be able to be honest and admit some of the missteps and when they have some failures. Leaders response to a crisis based on an ethical values and base principles. Personal and professional values is important to support this acting based on ethical principles. Beyond this, leaders should speak with conjure and very frank, especially in periods of uncertainty. Authentic leadership encompasses honesty, concern and benevolence. We need to try to sustain trust and especially trying to keep that in our relationships. In conclusion, trust leadership is needed for transformative and collective action in times of uncertainty, especially during the pandemic. For leaders to instill trust in the forward, they must take appropriate action via preparation, planning, seeking information and intelligence leading adaptation. However, it's important also an ongoing responsibility and accountability, developing and maintain this trust in circumstances like a pandemic sometimes is a very dynamic process that we need to be able to change. As COVID-19 continues to play out over the globe, it's becoming a clear that trust ultimately also requires leaders to offer hope. Thank you. Thank you, Dr. Mount for that kind introduction. I wanna thank the Program Planning Committee for inviting me to join this team of prestigious speakers for the Leadership Academy. I'm also really proud to represent leadership from the perspective of a nurse leader and recognizing many nurse heroes across the world who have stepped up to care for the many patients who are in the throes of this global pandemic. I have no financial disclosures to report. I have no financial disclosures to report. So in this session, we were asked to present a historical summary of our career in critical care and leadership. My beginnings were in a critical care unit as a novel nurse without any critical care chaining. I had to learn how to read EKGs by myself and I was worried to death that I would hurt someone inadvertently. You will notice that the nurse in this picture is wearing a cap. I did too. I knew then that it was important for me to get an advanced education early on so I would practice with science rather than with tradition. I went further in my education to become a clinical nurse specialist in the critical care field and then went the academic environment where I learned how to teach. I had a knack for leading teams so became a nursing operations manager and education director in a foreign country for a few years. Upon my return to the United States, I went back to my roots in the ICU and I was a critical care educator for some years. Once I had the opportunity to resume an advanced practice role, I was very active in critical care and I partnered with doctors Lauren Nelson and Michael Cheatham on a collaborative practice teams to bring evidence-based practices to the bedside. I was so interested in the physiology of critical illness that I was inspired to earn a doctorate in nursing in advanced medical physiology. From there, I went on to become a clinical researcher and later was appointed to director of a research in advanced nursing practice where I had the privilege to mentor clinical nurse specialists and budding researchers into their role. Later, my role was elevated to corporate director for the center and it allowed me to sit at the executive nursing team at the organization where I can influence nursing practice from a broader perspective. Professional practice for me was really mostly with SCCM. In 1989, I met a physician at Orlando Health who was new, Dr. Jay Falk. He has been with SCCM for years. He inspired me to join SCCM at the annual Congress and I was so thrilled that I've never looked back. His influence over my career was profound as I was so interested in his research on lactate with the late Hal Weil. It was so easy to be a part of SCCM as it was so inclusive of all critical care disciplines and collaborative practice was very important to me. It inspired me to start doing research and presenting posters, then sessions, then joining leadership ranks at the society and I've been an engaged and active member and leader for SCCM ever since. Doing these things have allowed critical care practitioners to contribute and advance within professional societies, including fellowship. Now let's get on to leadership. In November this past year, I was fortunate enough to attend a leadership program at Orlando Health that featured one of my favorite leaders, General Colin Powell. In his inspiring presentation, he outlined several things that just resonated with me about my feelings about leadership. These on this slide are key takeaways from his presentation and those that I aspire to emulate as a leader in critical care. To have integrity, to build trust, be a servant leader, be humble, earn the respect and include frontline experts. You will hear some of these things in the next number of slides that I talk about my experiences as a leader. And while Dr. Colin Powell talked about leadership as solving problems, the day soldiers stop bringing you their problem is a day you have stopped leading. And while we're not soldiers in a war, we are fighting battles with critical illness, trying to take lives every day. Thus these principles are still important in critical care practice leadership. We were asked to share five things that we've learned along the way, or tips to others who aspire to be leaders in critical care. The first is to be a leader in critical care practice. And the second is to be a leader in critical care practice. Or tips to others who aspire to be leaders in critical care, whether it's at the bedside or in a boardroom. This was really hard for me to choose, but these five things may be helpful to some of you who are considering a path to leadership. There are many paths to get there as you will hear from other speakers in this session. First, raise your hand. I've learned that oftentimes people are afraid to do this because they don't think their voice is important or afraid what others will think of them. I've found that in clinical practice and in professional organizations, volunteers are always needed and wanted. There is a need for many disciplines at the table for SCCM and in critical care leadership groups, including those at the unit and hospital level. If you even have a slight interest, don't be afraid to raise your hand and volunteer. And if you're afraid, be scared and do it anyway. You will be glad you did. Getting involved in things you particularly don't know about gives you the opportunity to gain expertise in new areas and helps you grow. Diversify your skills portfolio just like you would your financial investments. You are more valuable as a team member with multiple skills than a one-trick pony. Another take on this tip is to raise your hand when you think something is wrong or to stop an error. It takes courage to do this, but it's really important to stop the line when needed regardless of seniority or rank. This is our oath to prevent harm in those who have trusted us in their care. The one thing I've learned as a leader is that you have to be present to win. Team members at the tip of the knife where care is rendered are longing for leaders to listen and have a physical presence. Those leaders who sit at their desk every day are missing out on important information relevant to clinical practice and the ability to recognize things that are getting in the way of clinical practitioners doing their jobs. Removing obstacles to support team members is a key attribute of a good leader. One of the most important things one can do as a leader to simply listen and listen hard without talking. In a new house my husband and I just built, there are high ceilings with a cupola that the smallest of sounds echo throughout the house. So much so that we literally have to be in front of each other to understand what we're saying. This is true with being able to hear others and filtering out the noise. Physical presence is so important and demonstrates their willingness and interest in them to be there in person to support and listen. This has been a challenge during the pandemic and has limited our abilities to physically be present. Virtual meetings aren't as good, but at least you're present in one way or another. Have you seen this on the left? Have you done this? This is what we used to see before social distancing at the kitchen table or restaurants. We all know the dangers of texting and driving is you're not paying attention to what you're doing or where you're going. The other photo is one I took a few years ago in the ICU where they were making rounds. Everyone was looking at their phones or computers while the staff nurse in the center is trying to give a daily report to the critical care team. In meetings, cell phones are like crack cocaine. It's so odd to them that they're not actively contributing to the conversation in their team. Put down the crack pipe is a good tip. If you're looking at your phone while other people are talking to you, you are conveying that they are not important to you as what is you have on your little screen. Fast things fast, slow things slow. I use this a lot. There are times to move fast like when stopping a bleed or inserting a chest tube to relieve a tensioned pneumothorax. Then there are times to be slow like when evaluating the root causes of problems or trialing a new process. I often hear executives say, we are piloting this new process when in effect, they mean that they are rolling out the new process as often there are no metrics or re-evaluations with adaptations done in response to that pilot test. Quality improvement has rapid cycles as you know, but they are iterative and build on one another as new metrics are made and improvements are discovered. This just simply takes time. For evidence-based practice, one article does not best practice make. One must go through the literature and scour out the articles with best evidence and summarize the impact and their potential use in their population. It simply takes time to assess, plan, implement and evaluate outcomes from initiatives. I've been at leadership meetings where there are discussions about how to quickly change things right now. Very few things change fast unless inclement weather or viruses are involved. To be effective, leaders must give teams a time to go through these processes well. Otherwise, you'll be back at the table again, scratching your head and wondering what went wrong. Happy Groundhog Day. Another take of this is slowing down on things that could avoid harm. Taking time out before doing a procedure, ensuring the patient's identity, checking for allergies are all examples of time to pause and make sure all things are right. And defer to the expertise at the front line. Most leaders in critical care medicine were good practitioners at one time or another and promoted into higher roles. Don't forget where you came from and the expertise you gained at the clinical practice and its value. Be sure to include key stakeholders in making decisions for clinical practice. As for their ideas and input. As leaders, you are out of the groove of things. So to be sure to get the best information from the people who are on the front line. I just recently conducted two studies on nurses at the front line. One on perception of safety and the other on from the response to the pandemic. In both studies, nurses emphasize the importance of having someone listen to them and include them in decisions that impacted their work. We know while leaders want to be successful in making good decisions for their team, it's important to get the best and direct information from them about potential issues you may not be aware of from a practical or clinical standpoint. Some leaders zoom straight to their own six inches in their head to determine what's best without including the front line team members for input without help with making decisions. This will come back to bite you. Inclusion shows respect for professional practitioners who are liable for the care they render, particularly under your leadership. This will earn you a lot of respect in the end. Be nice and play well with others. This seems almost too easy to say that it cannot be said enough. There isn't enough kindness in this world and we've seen a lot of division between people this year. I come from the Southern U.S. where the culture for folks is to be nice with one another. And as the quote goes, you can catch more bees with honey than vinegar. I see the fatigue and despair in the faces of our resilient caregivers after caring for others all day, particularly during this pandemic. It just doesn't take much effort to reach out to be kind to someone else on the front line. That might be the only thing that helps them get through their day. Being kind is an active process by being respectful, humble, authentic, and actively being there for others when needed the most. Observing and responding to those who are struggling to get through the day is a caring behavior and important aspect of an effective leader. Playing well with others goes a long way in leadership and critical care. I've learned a lot from collaborative practice across disciplines and roles, particularly with SCCM. For me, the definition of collaboration is, I need you and you need me. Otherwise, why do we need to collaborate at all? This is especially relevant in critical care where patient care is a team sport. And being a good sport is a sign of a good team leader and a good team player. Remember that person you are working with today may be intubating you tomorrow. So in summary, active cultivation of a wide variety of experiences leads to multifaceted roles. While I'm considered a nurse executive, I'm still engaged with leading corporate initiatives for patient care, such as sepsis management, prevention of harm, quality improvement initiatives, and recognition of critical illness outside ICU and escalation of care. You will find that you never really leave a job, as you always take what you learn with you and carry it into your next role. Sometimes I think I'm just lucky, and feel lucky to have been blessed with so many opportunities. Well, so here's a few notes about luck. Frank Clark said, "'It's hard to detect good luck. "'It looks so much like something you've earned.'" Richard Bach says, "'You are never given a wish "'without also being given the power to make it come true. "'You may have to work up for it, however.'" And Ralph Waldo Emerson says, "'Shallow men believe in luck. "'Strong men believe in cause and effect.'" So with that, I wanna thank you for taking the time to attend this session on leadership. We will be available to answer questions for you at the end of this session. Thank you so very much. Hello, I'm Jessica Bunin. My leadership training began at the United States Military Academy at West Point in 1992. Since that time, I've been a doctor in the military for 20 years, deployed twice to combat zones, and held numerous leadership positions. Here are some of the biggest lessons I've learned along the way. I hope they're helpful to you. For our objectives today, we're gonna talk about these five tips. So we're gonna talk about creating a safe environment for your people, monitoring them for burnout and building resilience, working on some goal setting, talking about mentorship, very importantly, learning how to say no. And as we go through all of this, I'll introduce you to some helpful resources that have been invaluable to me along the way. So number one, creating a safe environment. Under the best of circumstances, the ICU can be terrifying. Add in a pandemic and exhaustion, and the fear multiplies. The best thing you can do as a leader is create a safe environment. Psychological safety means nothing you say or nothing you do will be used against you. You can ask any question, you can be wrong, you can say whatever you need to say, and it'll be taken well by others because they assume that you mean well. You can create psychological safety here in your environment. Everyone benefits. To do that, you have to develop a trusting environment, and you must listen to others with empathy. Psychological safety is not the same as comfort. If you look at this two by two diagram, we really wanna keep people in that lower right hand corner. We wanna help people grow and make progress. We don't want to hurt our patients. We don't wanna hurt our people. We don't want people to stagnate. We really want them to be pushed. We do want them to have some discomfort, but also have that be a safe place of discomfort. With respect to trust, how do we develop trust? Well, there's three factors that are essential. The first is we have to all be logical, right? I have to know you can do it. I have to know that you're going to think through problems, and I have to know that you mean well. If you're a conspiracy theorist who doesn't trust what I'm saying, it's not gonna work. Then we have to practice authenticity with each other. We have to be vulnerable to each other. We have to experience the truth of each other. And then finally, we have to be empathic. We have to care about each other's success, and we have to believe that we each care about each other's success. Empathy is the ability to understand the struggle and perspective of another combined with the capability to communicate this understanding back to them. In the words of Brene Brown, if we can share our story with someone who responds with empathy and understanding, shame can't survive. As a leader, you must be approachable, but when you're approached, you must also listen with empathy. Here are the two key resources that have helped me, Amy Edmison's book, The Fearless Organization About Psychological Safety, and Brene Brown's Dare to Lead. Moving on to factor number two, monitoring for burnout and building resilience. I mentioned the importance of psychological safety in stressful environments, but even with the most supportive environments, healthcare professionals will struggle with burnout. It's often the folks we least suspect who are struggling the most. Fortunately, they also are, or can become, the most resilient. To start with, we don't need to ask a 22-question Maslach burnout inventory or a 16-question Oldenburg burnout screen. You can just ask, do you feel burned out from your work, or have you become more callous towards others since you took this job? Those questions in and of themselves can help you identify who may be struggling, but you have to ask. Fortunately, and once we do ask, we know that there are leader behaviors that decrease burnout and increase job satisfaction. This was a study done by Shana Felt. He came up with these leader behaviors that we can all do. We can inspire others to do their best. We can encourage employees to suggest ideas for improvement. We can recognize others for a job well done. These are all on five-point scales, so on this page alone, 50 points worth of information, and just one point increase is a 3.3% decrease in the likelihood of burnout and a 9% increase in satisfaction. If we combine this with Daniel Pink's book, Drive, this talks about, initially we thought that human motivation was based around the id. How are we gonna eat? How are we gonna procreate? How are we gonna survive? Then we thought motivation 2.0 was maybe it's all about reward and punishment, but when you have smart, successful people, really, it's mastery, autonomy, and purpose that drive motivation. If we look at this compared to Shana Felt's factors, characteristics, you can see they all fit really nicely. So this is what it's about, right? It's about doing these things that will improve the mastery, autonomy, and purpose for our people, keep them satisfied, make them resilient, and maintain job satisfaction. So step three is to practice clinical goal-setting. This is another way to build mastery, autonomy, and purpose. We have to encourage people to have a growth mindset and to continue to excel. Goal-setting is one excellent way to do this. So why is goal-setting important? Well, it helps us self-assess. It gives us an idea of what competence and expertise should and does look like and shows us how to get there. It energizes the behaviors we practice and tells us how we get to success. So this is why goal-setting is overall important, but I wanna tell you briefly why it's important to me. On my last ICU week, I had a large team and I had everyone come up with a clinical goal first thing in the morning. By the afternoon, we had to help every individual come up with an action plan to achieve that. So a grand total on our first day, we spent 15 minutes to a half an hour discussing goals and plans. And what did that change? Well, for me, it changed everything. Throughout the week, it changed the quality of feedback that I gave each learner because I knew what they wanted to do. But not only that, I found that all of the learners were giving each other feedback up and down the leadership chain. They were invested in each other and I was invested in their success. And I feel more invested in their outcome still after they're no longer on my team. The teamwork improved throughout the course of the week. Everyone had positive attitudes and had increased wellness through the course of the week. And I'm gonna go so far as to say it actually brought me joy. So during a time that was horrible, I will say that clinical goal setting changed everything for me at work. It could have been a devastatingly sad time. Instead, it was a very exciting, motivational time. So I'm gonna encourage you to try it. Step four, understand the benefits and challenges of mentorship. If I had to label one aspect of my job that I love the most, it's definitely mentorship. Over the course of my career, however, it's also been one of the most challenging. When we think about the benefits of mentorship, we think about professional development and career enhancement for the protégés, psychosocial support, overall satisfaction of how they are experiencing their environment. But there's also benefits for mentors. They're more productive, there's more networking, there's recognition when their protégés perform well. And what I really find is that it's quite rejuvenating. I leave excited and ready for more in the future. However, I want you to note this article that I published last year. It's in the, unfortunately, failures and surprises category of the journal. So again, while this is something that I'm very passionate about, this article really focuses on some of the ways that I've struggled and failed in my mentoring relationships. So some key points that I want you to take away is take care when you're committing to a relationship. Make sure you have the time and energy to do it right. And then you have to maintain boundaries. One of the things that I really struggled with was having really close relationships with my mentees and then taking leadership positions, where now my role with them had to change in order to have things be fair to everyone in the program. So keep in mind that you can't spend all of your attention with someone who was a mentee prior. It won't be fair if you're now a leader. So you may have to change relationships. Be careful about biting off more than you can chew. You are not there to be the psychiatrist for your people. You're not there to be their mother or father. So be realistic about what you can accomplish for them. And then finally, know when to say when. If the relationship isn't working, if you can't have a trusting relationship with that individual, it's time to find them another mentor. So keep those things in mind. You wanna have mentorships available to your people, but keep in mind that you can't do it all and there may be times when you have to set boundaries. When I'm struggling with mentor decisions, I find this as my Bible for mentorship on being a mentor by Brad Johnson, but also have your own mentors, have colleagues that you can turn to, have these intimate discussions with people to help you make the right decisions for your mentees. Finally, and I'm gonna say most importantly, it's really important to learn how and when to say no. Nothing can be more discouraging for a leader than to feel ineffectual in everything you're doing because you're trying to do too much. There is a very real art and skill to determining what offers you should jump on and which you should decline. As an example, when I was associate program director, I was offered a job as a chief of the Department of Medicine. I was excited and honored, but then when I discussed this with my mentor, he said, how's that gonna get you to your goal of being a program director? And it really made me stop and think. It was such a valuable question. So I'm gonna encourage you to ask a few questions before you jump to saying yes because you feel honored and excited. So ask first, who's asking, right? Is this someone who's going to make a difference in your future? Or is this someone who's gonna be really difficult to work with? Is this someone that you want to perform for and help? Or is this someone that is just going to be a struggle? What's the deliverable? Is it something you're passionate about and want to achieve? Or is it gonna be exhausting? When does it need to be accomplished? What's the timeline here? And does that work for you? What are the benefits? Is it gonna get you where you wanna go? Or is it gonna just be a dream? If you don't have the time and energy, there may be many obvious costs and many hidden costs. So take the time to think these through. Make sure you're confident in all of these answers. And then finally, decide this. Is it going to help you get where you want to go? If the answer is no, say no. So ask all of these questions. Have a firm story in your mind of the right thing to do for you in your future before you say yes to the multiple opportunities you're gonna have in your life. If you need to learn more about learning how to say no, and a lot of us do, we're not so good at it. We wanna make people proud. We wanna make people happy. We wanna show that we're good teammates and hard workers. So we're not good at this. So two books that might help. First is Boundaries. And the second is The Art of Saying No. So in summary, you can create a safe environment for your people, watch them for burnout, and help them build resilience. Practice clinical goal setting and help them maintain a growth mindset. Focus on the importance of mentorship, but be realistic about the challenges involved. And then really ask all of the right questions before you say yes. Learning when to say no is really valuable. And with that, I'm happy to take any or all questions you guys might have. I'd like to take this opportunity to thank Society of Critical Care Medicine and particularly organizing committee for this opportunity to present at Congress. So one of the things that I was asked to do was to give the senior executive perspective on leadership and to provide five tips, some of which I wish I had known when I was a little bit more junior as far as leadership. So as we start this presentation, I have no financial disclosures to make. And I'm going to start with my first of five tips, which is be yourself, everyone else is already taken. And that's a quote by Oscar Wilde. But what it really means is it's talking about having authentic leadership. So understanding that you need to be true to yourself in whatever leadership style you choose and not try to neglect that. And then finally, I'm going to talk about you choose and not try to necessarily imitate someone else. So when you look at some of the aspects of authentic leadership, one of the first things is to know thyself. So that means you have to understand what your own strengths and weaknesses are. Oftentimes this requires reflection, it takes experience, where perhaps things have not necessarily worked out as well as you would have liked them. And then you need to be aware of what your particular values are so that you can make value-based choices. And that's so that you're happy with what those choices are. And then you want to also be able to practice your values and principles. So not only do you want to tell people what your values are, but they want to be able to see you practice those values and understand that those are and see you do those types of things. That will make you much more trusted and will also give you authentic leadership. So if you look at authentic leaders, this is actually a quote from Harvard Business Review. They're ones that recognize that leadership is not about the particular leader's success or about getting individuals to particularly follow them, but rather with a successful leadership is empowering leaders at all levels of an organization. And oftentimes individuals say, well, I don't have anybody who's reporting to me as a direct report, but understand that there is ability to lead from wherever you are within an organization. And it may be that you're leading a committee or you're leading a particular task force or you're leading a particular project. So those types of things are also leadership opportunities, although you may not necessarily have direct reports or a title. And leaders also should inspire those around them and empower those individuals to step up and lead. Oftentimes I find people at the more junior levels often want to sit back and wait to be asked. And oftentimes you have to put yourself in the situation to be asked to do certain things. So my tip number two, and this is something I did not realize at a junior level on how important this was, is networking. And I'm going to tell you that networking in and of itself is not a dirty word. Now understand that networking means different things to different individuals. So obviously with a lot of the technology that's available and a lot of the social media, networking may be different for certain individuals, especially with the use of social media. And I'm going to talk more about networking in general and understanding the traditional mode of networking, especially as we're working more virtually, may give some additional challenges to individuals. So the first thing I'd like to talk about is some common networking myths. So when you look at what individuals say, well, I don't like to network. And a lot of the things that are common myths about that are that they feel it's phony and manipulative, which if you do it correctly, it should not be. They think it's designed to convince someone to do something against their will, which obviously if you're an authentic leader, it's not something that you want people to be doing because you want them to be true to themselves. It's not solely about politics and getting ahead. It's not about selling yourself, especially as a leader. And sometimes I see people do a lot of this. And also a lot of us who are involved with a lot of research and science are often very introverted and they think that it's only for extroverts, which it's not. And it's not about how many contacts you can amass. So looking at networking, I'm going to talk a little bit about some of the reasons for networking and some of the reasons it will help you career-wise. So looking at this, there's an operational side. So a lot of times when I'm given something that I don't know how to do or I don't have any experience with, there's often individuals typically internally, but sometimes I'll use people that are external as well who can help me get that work done, especially if it's something I haven't done necessarily before. And it also can often be current focused, meaning at a particular point in time in a particular job. So it's also personal. So one of the relationships that I've had the most fun with as I've gone along is the people that I've been able to meet and grow both professionally and personally. And I can remember numerous years where I went to Society of Critical Care Medicine Congress and one of the individuals who's a friend of mine would have a poster that was usually one or two down and we would end up being in the same poster session. And now I've known that individual for over 20 years and they're a close friend of mine, both personally and professionally. So using those types of opportunities to connect, typically a lot of these connections are going to be mixed, more external, but they can also be internal and typically you're going to share common interests. So when people look at networking, a lot of times there can be strategic issues as well, and they can be people who help shape your future goals and direction. So they may be someone that's in a position that you may want to be in at down the line who may be able to give you some insights into that position or the types of skills you need to acquire to get to that position, or sort of ask you where you think you're headed and what you might want to do. And that can be both internal, external, but usually those individuals who are strategic are a little more future focused. So some networking tips is you want to be genuine. You want to be able to really connect, find common ground and connect with individuals. And a lot of times it's going to be the quality rather than the quantity of your contacts. And one of the things I realized with networking is that the individuals that I met early on who were maybe five, six, seven, maybe 10 years or so more ahead of me would oftentimes be those individuals who then would be in charge of a society or in charge of a particular initiative. And because I had known them or I had done some work with them years before, they would reach out to me and ask me to help. You also want to ask open-ended questions when you're networking and you want to try to build relationships. And if you look at certain things, obviously eye contact is very important as well for networking. So my tip number three is something that you wouldn't expect. And I'm going to diverge just a little bit and it's going to be exercise and it's a productivity secret. And if you look at a lot of individuals who are very high up in companies, it's more where some of the literature is written, all of us as healthcare providers know the benefits of exercise. So we know that it helps us from a cardiovascular standpoint, lowers blood pressure as well as a lot of other things. But it's also a mood elevator, puts us in the ability to be able to handle things that may need resilience and gives us that stamina. So a lot of people also find that exercise is a mood elevator. So it's one of those things that will actually give you the ability to be more productive. So if you look at one of these, this was a study that came out of Boston University and it was actually who had workout equipment on site. It was two private companies and one public company. And what they did is they analyzed the individuals that had workout days. It was roughly 200 employees workout days versus those days they did not work out. And what they noticed was there was a 21% increase in work concentration when they worked out, 22% more completed work on time, 25% had more work without unscheduled breaks and 41% felt more motivated. So I know it can be very difficult when you're working in the intensive care unit and you can say, well, I don't have the time, but if you can at least take some time to exercise and to give yourself a break, you might find that that actually helps your mood and actually helps your productivity. So the next tip I'm going to give you is one that was very difficult or more challenging for me at a junior level, which is to reach outside your comfort zone. So sometimes we get so focused on being able to do things well that we don't reach outside to be able to have growth opportunities. And one of the things I want you to think about is when you leave your comfort zone, that gives you learning opportunities. And as you take those sort of baby steps out of your learning zone, your comfort zone, that's where learning opportunities can happen. And obviously you want a balance coming outside your comfort zone. So you can see here the comfort zone, which is in the green, and then you can see growth and opportunity, which with the baby steps coming out of your comfort zone, or sometimes you may make a little bit of a bigger leap, will allow for growth of you both personally and professionally, as well as may open up other opportunities as you garner additional skills and experience. You want to try to stay out of the red zone because that's going to be more where there's paralysis, overwhelm, and it won't be as much of a growth and opportunity experience. And that's what a lot of people do when they're going outside their comfort zone is they probably go too far outside their comfort zone. And individuals know when they're doing things that are coming outside their comfort zone, they know to ask for help as well and to speak with others who have experience. So one of the things I'm going to give you a quote and says if it scares you, it might be a good thing to try. So a lot of times we're reluctant to step forward and try things. For instance, a lot of people have difficulty with public speaking, and it's a lot of that will come with practice and having individuals evaluate you, but there's something that you're probably going to need to be able to do in your career, especially if you're going to ascend to a leadership position. One of the other things I want to spend a couple minutes talking about is also as you reach outside your comfort zone is what John Maxwell calls failing forward. And that's turning mistakes into stepping stones for success. So as far as you look for failing forward, you have to understand that learning is inevitable, so embrace it and try to use those failures as opportunity to gain that experience, perhaps realize there was a skill that you didn't have. And I'm not necessarily going to say failures, but more sort of a course correction so that you're able to learn from those particular experiences. So I'm going to give you that failures do lead to success, and I'm going to give you three examples. They're actually sort of outside of medicine, but I think there are individuals that you all recognize. So the first picture on the left, you see Oprah Winfrey. So she was actually demoted from being a news anchor early in her career and told that she was not fit for television. Obviously now she runs a television network and has had an award-winning television show. The middle individual, which is Albert Einstein, apparently did not speak until about age four, was not able to read until about age seven, and his teachers told his parents that he was not going to amount to anything. Obviously now he's a Nobel Prize winner as well as a theoretical physicist. So, and then the third person on the far right is actually Thomas Edison. And when he was creating the incandescent light bulb, it took him 10,000 attempts. And rather than looking at each of those as a failure, his attitude was it was 10,000 attempts to create the light bulb. So those learning experiences and those opportunities where sometimes things do fail, oftentimes or things that people would define as failure often do lead to future successes. So when you're looking at career problems or when you're finding that something didn't go quite as well as you want, I want you to sort of take a step back and realize those are opportunities, perhaps in disguise that you can capitalize and then subsequently do course correction. Learn perhaps from the things that didn't go as well with those. Think about those things that you may need to obtain to be able to function. But a lot of those can be opportunities. The last tip, which is tip number five, is I'm going to say invest in yourself. So this means spending time to make sure that you are able to seek out mentors and sponsors as well as take care of yourself. So oftentimes mentors and sponsors, and we'll talk a little bit in a second on what some of the differences are, are able to provide you not only growth opportunities and training opportunities, but also to help you evaluate your skills and to provide additional skills. Also will have life experience that they're able to share with you or able to provide experiences that will help for your learning as well as your knowledge. And obviously look to help you become competent and whether that involves additional training opportunities as well. So one of the things I want you to think about, and it's one of the axioms that I've realized, is successful people never reach their goals alone. And the word team is together, each achieves more. So as you look at this individual pulling someone else up the mountain, as you go up the ladder and ascend into a leadership position, I want you to think about reaching back and also involving other people as others did to you coming up the ladder. So one of the things I want to take just a minute or so to talk about is mentorship versus sponsorship. And although they have overlap, I want you to think about some of the mentor relationship is probably a little bit more of a private rather than a public relationship. And the sponsor relationship is probably more public than private. So a mentor is most of us who are involved in medicine know it's going to be someone who offers advice and feedback for advancement, helps you build those skills that you need, the qualities and the confidence, also helps you decide on what your career vision and plan is, hopefully can help you get some of those high profile assignments that will allow you to garner some of those skills. And both the mentor and the sponsor are going to be individuals who commit to your long-term success. One of the differences is who switch into individuals that do more sponsorship, is those will be a little bit typically more of a public. So there are people who are able to give you high visibility and typically we talk about more of this within company stakeholders, but it is also within our field of medicine, able to connect you with influential people so that you're in the know for insider information, also helps you strategize some career moves. So there may be opportunities where you can choose one versus the other and they may be able to help you say, well, actually this one would probably be better than the other. And ultimately a sponsor will be someone who can stake their reputation to advocate for your promotion or for you being able to do a particular thing. So looking at our summary slide then, I'm just going to go quickly through our five tips. So the first one is authentic leadership, be yourself, everyone else has already taken. You use the power of networking and understanding that networking can actually help you be more productive in your job and also make your job easier. And it also makes your job more fun as you have individuals that you're able to connect with. Exercise, I know it's difficult sometimes with our clinical schedules for those of you who are all providing clinical work, but it is a productivity secret and be able to reach outside your comfort zone and be able to fail forward so that you're able to gain additional skills and then invest in yourself. So don't hesitate to seek out mentors and sponsors. Most individuals who have had those individuals as they've risen up through the hierarchy are actually find it enjoyable to help others as mentors and sponsors. I'm going to leave you with two final things, which is be authentic. You can see here on the left, the fake duck versus the real duck. Obviously stay true to yourself. That's really important because that is very important for you to be able to be authentic. And then one of the other axioms is never stop learning. So thank you for your attention and we'll be able to take some questions and answers during the time period. Thank you. Well, good afternoon. Welcome to the live question and answer portion of the ISD Leadership Academy session. I wanna thank all of our panelists for being here today. I learned a lot from each of your talks. So I know that I have a whole list of things to take back and reflect on. We've been getting some great questions in the chat. Please keep submitting questions. And as you all vote them up and they come to the top of the list, we'll go ahead and address them. So the first question that populated that I'd like to address is, what rejuvenates each of you as leaders? What fills your cups that you can continue to lead? I know this is something I've struggled with personally over the last year, given the conditions of the pandemic. Many of the things that I use to rejuvenate are off limits at this point in time. So spa trips and getting my hair done and going out and just kind of getting away from the chaos that is my house with young children. When everything's shut down, that's harder to do. So I was wondering what each of you would tag as the thing that helps you rejuvenate or refill your cups that you can go back into work the next day and be a fully authentic and present leader. And we'll just kind of go with how I see people on my screen. So Brenda, we'll start with you. No, I think from a personal basis, one of the things and I have it as one of my productivity tips was exercise. So even though I may not necessarily feel and we've been a little bit more limited with the pandemic. So for me, because I live in Florida, luckily I'm able to go outside, which also helps. And I'm able to, and I won't say I run, I just jog, but it's good. And I actually do a book on tape while I'm jogging. So I actually get some of my reading in as well. So that helps rejuvenate me, helps me sort of separate a little bit as far as professionally what rejuvenates me. For me, it's the success of others. So having, trying to get people the things that I think that they want to do to help advance their careers, I find very satisfying when I sort of watch that progression and I see them be successful and trying to help others. I find that very, very rejuvenating as a leader. That's great. Daelene, what about you? Well, personally, I love to travel. So it's really been thwarted just a bit. We just started building a home in Costa Rica and finished it in January of 2020. So I couldn't go back and visit, but it was still a lot of fun. And I really enjoy traveling a lot and being in other countries and meeting people and actually like being in a jungle. Professionally, I'm much like Brenda. I really see in the success of my team and people grow is very satisfying, rewarding to me. Sometimes to fill my cup, I would do something very odd, like go to the waiting room of the patient's families and sit there for a little bit. And I would really kind of get the gravity of what's going on there. And it would really kind of bring more purpose back to what we were doing. And just being on the front line with team members really helps me a great deal. Great, Jorge? Yes, and thank you. Thank you. It's a very interesting session. And probably as many of you know, I'm living in Belize. I mean, I have those days to have most opportunity to enjoy nature. That is something that I also during the pandemic, we start to love a little bit more to trying to enjoy what we have and also spending more time with family. And since a professional point of view, in the last couple of years, we are trying to basically dedicated to write some books and that we also recently published a couple of volumes. And then that is important just to change a little bit the routine that we have as a leaders. Now we need to trying to essentially trying to change some habits, things that we routinely do just to trying to change. Because as we know, leaders is a very exhausting thing and it's not only for us, but also for our mentees. Jessica, what are your thoughts? Yeah. What rejuvenates you? Yeah, on the personal side, my puppies are lifesaving, no doubt about that. But professionally, I actually reflected on this a lot because this past year, we had a lot of loss in my family and I was really struggling emotionally for a while and working really hard and trying to figure out how to convert all of our education to virtual and everything seemed very overwhelming. But I came home from the ICU one afternoon and I came home really late. My wife said, what's going on with you? She's like, you seem really happy, you're doing really well today. And I was like, wow, like what was different about today that really got me over the hump? And I realized that I had spent the last two hours of my day mentoring one-on-one, which is really the most rewarding part of my job, I think. No matter how many people I, how many patients I care for, people I see and teach in a session, I always find that the one-on-one mentorship and seeing those individuals grow and change is really the most rejuvenating thing for me. I think professionally for me, what's the most rejuvenating is getting back into the ICU. So in my previous position, my only opportunity to do ICU time was on weekends. So I would take one weekend a month and there was something so refreshing and resetting about just being able to focus on clinical medicine and teaching residents. I didn't have any meetings, I didn't answer my email, I didn't have anybody knocking on my door, asking for signatures on things. It was just Friday afternoon to Monday morning where I could just focus on clinical medicine. And it helped me remember how much I really love being an intensivist. And so for me, when I need my professional cup refilled, I go back to the bedside and I go back to teaching residents. So there's a great question, which I think is a really tough question. So I'm excited to hear what you all think about this. Does your ability to be a great leader rest on the shoulders of your boss? Or can you get there regardless of your professional support system? So who would, I don't wanna keep calling on people. So who would like to take that question? Kristen, I don't mind starting. Okay, great. I would call that not an or. I think that absolutely clearly having great leaders around you and great mentors around you is ideal. But I think you also need a professional support system even if you don't have those leaders. And I think this is one significant upside to the pandemic is that I think we're getting a lot more courageous about reaching out to people that share common interests or that you've seen speak or publish in a topic that's very interesting to you. And you can make a lot of personal connections there that can be very beneficial and you can get all the mentorship and leadership education you need almost from a distance now. And so I would say that that's something that's changed for me over the past year is that I've met people throughout the country that I never would have met otherwise that have really enriched my life. And so I would just encourage people to take that risk and take that step to send an email to someone they don't know and just ask for help, tell them their situation. I think people will be really surprised at how receptive others are to people who wanna grow and lead. I think that ties into what Brenda was talking about in terms of networking and that's networking is not a dirty word, right? And so if you want to expand your career and you don't get the sense that that's gonna happen with the person who happens to be your immediate supervisor, that's where your network comes in. And so you've gotta build that network and you never know what opportunities are gonna come from that network that offer a reprieve or a chance for advancement or just a chance to kind of continue to build on the network. I don't know, Brenda, if you have any more thoughts about- So I agree, interestingly enough, any chair that I've worked with, I've never worked with a chair that's been critical care trained. So when you think about that, it's not been, so for me, that my boss has not been critical care trained. So it's also reaching outside the institution for people that maybe have a lot more level of expertise. And I had that same experience that you just talked about, Kristen, which is that I actually had someone encourage me to reach out to someone who was very high up in one of the academic institutions and says, you know, actually he'll love to hear from you. Just write him, just tell him what's going on, see if he'll spend some time to talk to you. And now he's a very close friend of mine on critical care and somebody that I call for advice they can give me. And sometimes it's better to have a little bit of an outside perspective, because I think sometimes with your network, sometimes you're so busy internally that someone that's a little bit at an arm's distance can also give you some more advice or some more perspective on perhaps something that's going on that you may not be able to solve or be trying to work through. And that's where your network becomes very valuable. Thoughts on support system versus direct supervisory chain for progressing your career? No, I think support comes from a lot of different areas. And I think you have to decide where you think that support is going to be. Sometimes what will happen is that you may be headed on a different track than your boss came up and your boss may honestly not know what sort of things, let's say for instance, you see yourself more going into more of an operational job within the hospital system and your boss may not have any experience with that. So reaching outside, you don't necessarily have to have, it would be, it's easier if you have their support, but at some points in time, you have to ask as well. Sometimes they may not know what you need for support. So I think Jess, you were saying that a little bit yet, or you were as well was, you have to ask, you have to raise your hand and you have to ask because a lot of times people don't understand and being able to understand where they're coming from as well. So hopefully you can get the resources that you need. Yeah, also in our personal experience, that's a very important note and we need to ask for help. And sometimes this is the most important or more difficult thing that most of the times people, they don't want to ask for help. But as you already been saying, the ask for help is important. The pandemic is basically teaching us an important thing that we need to have so many people outside, so many that are willing to help us and to put everything, all the efforts together. Great. Eileen, I want to come to you. Oh, okay. I was going to go to the next question, but finish that and then I'm going to come back to you for the next question. No problem. I mean, I agree with what everybody has said. It's very important to know what you can and can't do. And my boss is in operations, so she knows nothing about the clinical side so much. So she leans on me to be able to be the clinical advocate and expert. So help by her setting the compass, she basically points the direction and counsel me to lead. She counseled me to get what I need, to do what I need to do my job. And I lean on her when I need her help to get me the things I need to do to do my job. As far as my practice, I've always felt very comfortable with reaching out to other people because I don't know that much. The longer I stay in this field, the less I know. And so I'm, you know, I love reaching out to others and learning from other people and especially when it comes to leadership. That's great. I agree. So support can take a lot of different forms. There's a question about career pivots, which I think is interesting. I feel like very often, or maybe it's just me, very often you feel like you kind of set left and right limits for yourself and that's your career track and you just march forward until you're done. How do you identify your next career transition? And did that become more difficult as you went up in leadership responsibility? I know that some of that is programmed in based on your education, right? So, you know, for physicians, you go to medical school, you do your postgraduate training, you might do a fellowship and then it's kind of marched out. But I'm interested to hear what career pivots or transitions you've made and how you knew it was time to transition to a new job. Wow. That was a hard one. I thought you had a hard question. I'm a poor career planner, I'll be honest right up front. I did not set out to do what I have done. I'll have to be honest with you. I have made the best out of what was afforded to me at the time and I just took a right or took a left and I ended up where I am. I really did not have a career path in mind. All I knew was I wanted to do a lot of different things and well, I have. So, you know, my career really looks like a quilt of very different experiences and it's really helped round me out. So I'm okay with how I ended up. I like that analogy of a quilt. Anybody else have thoughts on career pivots or transition from one job to the next, how you knew it was time or maybe what spurred you on to make a career transition? So I think one of the things that I talked about a little bit was sort of that failing forward or opportunities and looking at course correction. So sometimes I've used some of those opportunities to say, all right, maybe I'm off course from where I think I need to be and then deciding is that where I really wanna be versus where I am right now and deciding whether I need to make that right hand turn. I think you have to look at the opportunities too that come your way and decide, is this something I wanna do, looking at the benefits and looking at what potentially may be some downsides as well as you move into those leadership positions. And I think one of the things that I've come to realize and I've tried to teach my adult children now who are both one into college and one's in graduate school is the things that come easy to you are in your skillset. And when you're junior faculty, you think everybody can do those. And it takes a little while for you to sort of get that lens and look at those skills that really come easier to you because those are the ones that are gonna be in your natural skillset and where you may wanna look at taking your career and pivoting it. And sometimes for me, it's just been that the opportunity has become available but I've made that pivot. I've actually had some massive pivots. So I started out being a physician as being an outpatient psychiatrist and really realized that it was a mentally and emotionally draining job for me that I knew that I wouldn't be able to continue happily long-term. And fortunately, I had friends and family around me that were willing to emotionally support me as I made a transition and shifted to the critical care world from the psychiatric world. My first six months of fellowship training were terrifying and I don't know that I slept much through any of that but I always had sort of cheerleaders helping me keep going with that decision and definitely not a regret in my mind at all. I don't know that I would be happier doing any other job other than critical care. So that's been wonderful. But the other thing that's really been helpful to me is I try to jump on any interesting educational opportunity that still comes my way, whether that's a day course or a week-long course or something more extended to that, like a master's degree or something along those lines. If you asked me five years ago, I'm not sure that I actually knew what faculty development was. And now I'm an assistant dean of faculty development. And that's really because I jumped on some awesome educational opportunities along the way. And so that's one of my high recommendations is if there's something that's even remotely interesting to you, like dive in and check it out and see if it does stick. Yes, and from my personal point of view, I moved to Belize with the idea, well, essentially with the offer to start critical care from scratch. When I moved to Belize, we didn't have any critical care unit, no, any setup. Meaning that the main goal for me was to start the critical care medicine from scratch. And then I'm glad to say that that was in 2002. And then from now we have a very well-established at least four different critical care units in the country. We have a coronary unit. We have many other things that I'm glad that I made that decision. It was a little bit difficult for me at the beginning, but locally we put and left something and a small legacy in the country. That's great. I too made a massive career pivot recently and Jessica is smiling because she knows about today. So I left a health admin job and decided to go back into GME as a fellow. So I'm a fellow in emergency ultrasound this year. And for me, what I found myself thinking about was what my personal priorities were. And it was great advice that I got from a mentor a couple of years ago, which was to settle what my priority list was. And whatever my list was, was my list. And then to try to align my career choices along with those priorities. And so what I found as I was doing those kind of one weekend a month in the ICU was that I really missed clinical medicine a lot. And the jobs that were being offered to me on the administrative side of medicine were not going to let me get any more time in the ICU than what I had last year. And so one way, and as Jessica said, a friend came to my office and he's like, hey, I'm applying for the emergency ultrasound fellowship. You should too. And it was something I had always thought about. I had actually looked into it about 10 years ago and then got talked out of it. And so I thought it was crazy. I am, I'm not that old, but I'm old to be going back into fellowship. And, but I got some encouragement from some mentors and some friends and some peers and I did it. And it's been incredible. I was scared. I had sleepless nights. I thought this is the dumbest thing I've ever done. I'm derailing my career. I've managed to stay involved in leadership from a strategic perspective outside of my organization, but it's been a really refreshing year for me getting to focus on my priorities, which is returning to clinical medicine, learning a new skill. And then the bonus is I get more time with my family. I have three, three tiny little boys under the age of six. And so sometimes you'd have to take a leap of faith. And if I've found that if you align those leaps of faith with your priorities, for the most part, it's gonna be okay. It'll end up okay in the end. Jorge, I wanna come back to something that you said. There was a question that I thought was very intriguing and you had mentioned that you've built your program from the ground up over many years. And so one of the questions was, how do you determine successorship? So how do you decide who's gonna follow you in leadership positions? Is that a process driven thing? Is that a personal, you mentor your replacement? How does that work? How do you all do that? And Jorge, I'd like to come back to you to start that question off. Yeah, that's a very interesting question because as we mentioned already, being in leadership, it could be very exhausting. And also we need to definitely plan our path of moving forward and also to help prepare the successors. Because we are not be eternally in a one position and that we did. I also, in the bigger ICU that we built in 2012, we decided that we want to mentor a few doctors that they became intensivists and they are already taking the leadership from those units. Now I move on already from that and they are already basically leading the unit. It's good because also it's encouraged. We feel happy because we can see that the work and the things that you taught and you prepare essentially is being followed. And of course, they are bringing the new ideas as well. Anybody else have thoughts on successorship? And I think some of that ties into mentorship and some of that ties into sponsorship as well. So it's interesting when you go into these companies, basically, if the CEO were to suddenly have something happen, they have four people that can step into that role. We are not trained that way in medicine for that type of successorship. But from my perspective, looking at the individuals that might have an interest, starting them early, giving them the type of tasks, seeing if they like it. Some people try it and say, this is not for me. I want to stay more at a certain level because when I become the boss, I'm not everybody's friend anymore. There are certain personalities that don't seem to do as well with it, but giving them those pieces to see if it's really what they want to do. And I had a Dean at one of the institutions I was at who said that part of a program sometimes is to figure out what you don't want to do. So, because if you go into something that you really don't enjoy, then you're not going to be happy. And he felt very strongly about that. I can say that succession planning is, from what I've seen, is not done very well. Especially at the executive level, I find people try to hold on to their jobs as long as they can because they have a short shelf life. And so, sometimes there's whispering behind, who's going to follow who, but it doesn't feel very robust like some places I've seen. And so, I decided I didn't want to leave it to someone else and started looking at my team and giving opportunities for some who were starting to be shining stars to start moving up. And just recently hired a new manager to start leading the team. So, I can back off for a little bit and give them a chance to really shine and give me a chance to back up. I would just say that really in the military, I almost feel like part of your orientation to a new job is figuring out who could take it over for you. We have such a rapid turnover rate in most situations. And even if you're not turning your job over, you can still disappear at any time for six or 12 months for a deployment to another location. And so, while I was learning any new job that I was ever taking, I was also thinking about how I can teach someone else to do that and asking around to people I trusted of who those people might be and how I might best prep them to do that. It's fascinating the degree of turnover and how much you have to really focus on that right from the get-go to ensure that someone is gonna be prepared to keep building on the goals that you've set and the culture that you've set and the tone that you've set to try to keep things moving in the right direction. I think what I've faced in terms of a challenge with succession, having left a couple jobs where I then sat on the panel to replace myself, was thinking outside of the same kind of three or four or five people circle of people that I know and trust. I know that they're good leaders and I know them because I have a personal relationship with them, they're peers or I've been mentoring them. So I think sometimes the challenge in a succession plan is making sure that you're thinking outside of the immediate circle of people that you know. And we see a lot of that as we talk about diversity and leadership when all I'm doing is nominating the same people over and over for things. For me, that's a challenge. And again, I think it comes back to how big is my network and who is sponsoring other people. So there are times when someone will contact me and say, hey, I heard you're looking for this position. I've got a really great person, can I tell you about them? So I try to do the same to sponsor people in those positions. But I agree, I think turnover is an issue both too rapid and then also people that you have to pry out with a crowbar because they're not taking away for a new generation of leaders to come behind them. And so there's some finesse there. There's another great question. So I'm gonna try to paraphrase this. We all worry about burnout for a very good reason. And we had some great discussion in your presentations about how to deal with burnout, but how do you protect yourself? So if you're a manager and you have 50 people that are reporting to you, how do you make yourself both available as a leader, but also protect yourself from everybody else's problems? And I will tell you that my tendency is that I take everybody else's problems and then they become my problem. So this is something I struggled with a lot, but I didn't realize I struggled with until I went back into fellowship when all of a sudden everybody else's problems were their own again. What are your tips or tricks for kind of creating that personal buffer space without being kind of cold and unavailable? Well, I think so it's a learning process. As you say, probably at the beginning, our enthusiasm to lead a program, we want to do as much things as we can, but over the years, I think so we learned that we need to start to trying to give some of the over responsibilities and probably this is the most difficult part that we need to trust people and we need to start to trying to give them some of the over leadership responsibilities and trying to share that bond because if not, it's very difficult that especially in those days with the pandemia is very exhausting. We need to learn how to, as one of the presentation says, we need to learn how to say no, no more. And we need to say, hey, this you take this responsibility and this one, because we can do, we cannot do everything. We need to learn that. I agree with Hidalgo, that Hidalgo, you're right. I tend to be a lot like you, Kristen, I'm a big empath. So I'm always trying to get in somebody else's shoes and understand it. So being an empath, really, you start feeling the same thing. So I've had to learn how to be present when I'm present and to be absent when I'm not. And so, for example, I'm doing better and I don't worry about it. I don't bring my computer home for the most part. And when I come home, I'm off. And it's hard to do because the tendency is to want to be there for your team and help them. So when I'm with him, I give them my undivided attention or I try to make sure I schedule time to be with them. And then when I'm ready to go, I'm ready to take my time off and take care of myself. It's been hard. It's not easy to do. I think that we talk about kind of the always connectedness with electronic devices. And one of the things that I found helped me was I told people that I'm not going to answer email after I leave. And I left at the same time every day. And mostly that was for child care reasons. I had a hard and fast have to be home by this time. And then I wasn't going to respond to text. So if you needed me, it has to be a big enough deal to pick up the phone and have an actual conversation, like make a phone call and have a conversation with me on my personal cell phone. And what I found was the only time that happened was when I was the ICU attending on call and the resident needed to talk to me. It was very, very rare that somebody felt that what was going on needed my attention at night, at home, or on the weekends that it couldn't wait until Monday. But just studying, and I would have been fine, right? If it's a big deal, I'm there. And there were some questions in there about how you handle administrative emergencies. I forced triage by saying if it has to come after duty hours, you've got to actually have a conversation with me. And that had a lot of people hold off until Monday. And 99% of the time, it was nothing that I needed to address at night or over the weekend. So I like that idea of kind of just setting boundaries. It's hard. I had a lot of anxiety about not being connected. But the more I did that, the easier it got. I think one of the other strategies, too, is that a lot of times people come to you and they want you to solve the problem. And taking it and giving the problem back to them with a list of questions and showing them that they can actually solve that helps them realize that they can be self-reliant. And a lot of the things that they may be bringing to you that are not huge, that need to be addressed right away, they can actually think through and solve on their own. And I always, years ago, read an article about who's got the monkey, which I thought was a great learning experience. If someone comes to you with a problem, you can either take all the monkeys and have an office full of monkeys, or you can find someone else to take the monkey, which I think is such an important learning point. You don't have to solve and do everything by yourself. You have a whole team or a whole hospital full of people that can handle bits and pieces of it. And I think that's the same for administrative issues as it is for leadership and mentorship. I think as a leader, your responsibility is to ensure that everyone understands the importance of mentorship and gets mentorship. You don't have to be everyone's mentor, but you can help sort of make some connections where you think things might work and people might really understand each other. You can pull the right person to handle some administrative tasks. You don't have to fix them all yourself, but you can set up the right circumstances so that other people are successful at solving all those problems or mentoring all those people. So I think reminding yourself that there's other people that have as much or more skills than you do, and to remember to take advantage of that instead of taking it all on yourself. So let's talk about meetings and leadership during meetings, which obviously has changed during the pandemic as things have shifted to virtual. I think that brings a whole separate set of issues dealing with virtual meetings. But as a leader, what advice do you have for new leaders dealing with both the squeaky wheel, so the person that always has to talk and is always offering all the solutions and answers to everything all the time, and balancing that with the person who is very out of their comfort zone and can't get a word in as well, which for me feels like referring my kids. And so I don't know that the same idea applies, but I've certainly watched that dynamic back and forth in a meeting with somebody trying to talk and then somebody else speaking over them. So let's make it a little more general, I guess, and your best tips and tricks for managing people during meetings when they have different communication styles. So one of the things I've learned, especially for individuals who are more introverted, is sending an agenda out ahead of time gives those individuals some time to think about it. They will probably want some thought time to contribute, and making sure that you have the opportunity to have everyone contribute. Sometimes when someone's spending a lot of time on a point, I'll stop them and say, we're on a little bit of a time. How many of you in this room feel that we should continue this discussion and have everybody show their hands? And if not, we're going to put that in the parking lot, or you may just say, we're going to put that in a parking lot for a later discussion and then continue on with the agenda, so that you keep the meeting moving and you get what you need done during that particular meeting. But also giving people an opportunity for feedback, or if someone is monopolizing it, there are ways, tricks that you can do to sort of bring it back to the whole group and say, do you think this warrants further discussion? Should we put it in the parking lot, or should we do it for five more minutes and then be done with this discussion? Yeah, I think so. The problem with meetings sometimes is that it can interfere with the productivity. I mean, that we need to be really, really wise as how to work on our meetings, and also as Brenda say, we need to try to prevent that someone monopolize and also to go over and over in a point, and we don't essentially don't move on. We need to be very productive. The meetings need to be trying to prevent to this meetings don't affect the productivity. Yeah, it's a skill to run a good meeting. It takes a lot, especially if you have some some free talkers, and I think, Brenda, your notion of having an agenda is very important. Sometimes I'll put time limits on there, and if you start the meeting out by saying, okay, we only have a half hour today, and we've got a really tight meeting, so if we get in some long discussions, we'll set these aside and so forth, and if I have somebody who's really talking a lot, and I'll try to defer to someone else who isn't, and I'll go around the room. I say, okay, we're going to go around the room and have everybody give their input on this, so everybody has to speak up, and so it it monopolizes a little shares more the time that people are getting together, and sometimes you just have to meet with that person outside and say, listen, I know you're very enthusiastic about this topic and so forth, but we want to give everybody an opportunity to present and things like that, so sometimes you have to call people out. That's great, and what I have found is that if these are people that you meet with regularly, so part of your staff, I tend to identify the extremes of either end, and then usually I will try to set up a meeting with them before the bigger meeting, right, so let that person that has all the ideas and wants to talk and has all the things on their to-do list kind of verbally vomit all of that out to you separately so that it's out of their system by the time the group meets, and then similarly engage with the person that doesn't quite feel comfortable yet in the big group to say, hey, here's what we're going to talk about. I'm interested in your ideas before we meet. Hey, I really like that idea. I'd like you to bring that up, and I'm going to come back to you in the bigger group, and I'm going to ask you to explain that to the group, so to kind of prep them beforehand and then give them that pre-encouragement that what they're going to say is supported, and I found you don't always have time to do that, but as you get to know the people that you're meeting with regularly, you'll identify those people that benefit from that kind of, you know, pre-meeting prep session or pre-meeting pep talk. Jessica, I'm glad you're back. We had technical difficulties. So we were just finishing up kind of the question about how you, you know, how you control either end of the spectrum, and I think this would also apply to rounds, right? I'm sure we've all been on rounds, and you have that one person that kind of jumps in and has all the answers all the time for every question and cuts people off, and then you have somebody else kind of standing in the back of the group holding their rounding sheet in front of their face, hoping they don't get called on. So thoughts about how you moderate those ends of the spectrum to make them part of a productive group. Yeah, I think it totally varies based on the situation. I think you're absolutely right. I think I caught the end of you saying, talking about the importance of reminding people that their voices are important, and sometimes I will literally say that in meetings or even on rounds, like, your voices are important, I want to hear them, because we spend so much time saying, mute yourself, you're not on mute, please make sure you're muted, that people might forget that we really do want to hear their opinions, their voices, their words of wisdom, their contributions to meetings, their contributions to rounds, and so I think reminding people of their work on the regular is a really important part of that. So question. The question submitter thinks that a leader must be able to compromise. What do you think about compromise as a leader? And for me, I don't know that I love the word compromise, but I interpret that as, what am I going to, what am I going to put my energy behind, right? So if there's an issue in front of me that is not very important, it's not affecting the overall ability of the team to meet their mission, whether that's clinically right there at the bedside or further up strategically, and you want to do it this way, go for it. Like, I don't, I'm going to put my energy and thought and my, maybe my fight or my stance behind something else. So I don't like to think, I know leaders compromise. Maybe it's the army in me that I don't like to, I don't feel like compromise means seed. It's more for me of a, I don't need to have control over everything in my environment all the time. So I can absolutely, if you, if you want to start rounds at 8.30 instead of eight o'clock because of X, Y, and Z, knock yourself out. I'm fine. Just tell me where to be and I'll be there because arguing with you about that and making you do it my way is not productive use of my time and energy. I don't know what your thoughts are on, on compromise or, or that give and take relationship between a leader and the people that they're trying to lead. So I think it depends upon what the point is for compromise. Obviously it's a patient safety issue and I know you would agree with this, Kristen, you're not going to compromise on that. I think what I try to look at is I try to figure out what the point of view that the, the leader that maybe doesn't, maybe doesn't want to go down the same track I want to and look for win-win opportunities because it may be that you're able to pivot them and, and not have to compromise on the things that are really important, but looking for opportunities where they're win-wins in those types of situations. Yeah, I really like, I like collaborating with the team and have them give input for decisions on a lot of things because that's what collaboration is. As I said in my talk, that is I need you and you need me, but there are certain times where compromise is, is not appropriate when there's a black and white situation, like you say, patient safety or things like that, or you just have to do a hammer down approach to something that's coming from up above. Sometimes we just, we can't compromise, but I think as a leader, we compromise quite a bit for the sake of everyone having some skin in the game and, and being able to be a part of the decisions that are made. I think a couple of things. So first, I think the, the best negotiation is always going to be when both parties walk away feeling like they won. And so I think if there's a way to work on individual negotiating skills so that you can make sure that you're hearing what everyone at the table truly wants and finding a way to meet everyone's needs at the table, then that's really your ideal situation. And that can often take a lot of work and maybe being called collaborative leadership or maybe being called compromising. I'm not sure how you would want to label it, but I think if you can figure out a way to get everyone on board, then that's ideal. But the other thing that I would add is that if, if you're feeling a strong need to, to fight a compromise, then that may be something that you really need to reflect on more and understand more. And like Delene said, to really ask more than just that one person that you're trying to compromise with, what that's about. And that may actually be a really valid piece of feedback that you're getting by someone saying, look, no, your, your decision's not right in this case. And they may be absolutely right, but sometimes getting some neutral voices to contribute or to just talk it through with can be really beneficial. So similarly, there's a question that just popped up that kind of tags onto that. So what do you do when you as the leader are in a discussion in public and there's open disagreement about what you want to do, be it at the bedside with patient care or, or from an administrative sense or an educational sense. So how do you handle open and open meaning public conflict with, with somebody else? I'm a, I'm a loud talker. So people will tell you that I just start speaking more loudly than normal. And I do not shy away from public conflict in terms of, you know, closed door meetings with, with groups, certainly not in the command group when I was there and when I felt passionately about something. But, but there is an art, there is an art to disagreeing in public. So what are your tips, tricks or pearls for disagreeing in public? I think that agree to disagree statement is always comes in very handy that, you know, I respect your opinion. I have a difference in opinion, but we'll just have to agree to disagree on this one. And if it gets really nasty, I think it's one you have to take outside. Yeah, I would, I would just say that the, it's really healthy, actually, to be able to have significant disagreements with people and display working that through in front of people. As long as you can maintain appropriate language and appropriate tones, and appropriate levels of respect, then I think that that's actually ideal. You don't want a situation where people are afraid to bring things up to you, or you're afraid to say things that are not appropriate. And you don't want to put things up to you for how you'll handle them. And you don't want a situation like that psychological safety is real. And if you can role model, having disagreements with people and solving them in, in real time in front of people, then I think that that's actually ideal role modeling. It's just a matter of making sure that you're able to keep your emotions in check, and that you're able to read someone else's emotions well enough to be aware if they're able to read their own emotions in check. But I think that that's hugely important to learn how to do. I think as soon as we start shifting all of our feedback to anonymous and all of our comments to anonymous, and we stop learning how to have public disagreement, that's productive. I think that's really dangerous. And to dovetail to what you're saying, Justice, I think it's important to hear other viewpoints, because they can at times change the way that you as the leader perhaps view something. But also having looking at the opportunity on when do I need to de-escalate this, sometimes oftentimes making sure you understand and repeating back to them, this is what I heard you say. And seeing if you really are understanding what their, what their point is, because sometimes it's, it's clearly a miscommunication and trying to make sure that it stays in that civil type of tone, because no one wins when there's a big disagreement that ends up being where you're acting unprofessional. Yeah, I agree. I have found that very rarely have I gotten into a disagreement with somebody because they weren't also coming from a similarly good place with good intentions. So what it ended up needing to happen was that we both needed to work our way around to figure out where the other person was coming from, and then arrive at a solution that worked for both people. So I guess that's compromise, but if you can put yourself in the other person's shoes for just a couple minutes and say, why, why are they stuck on, on this? Why, why do they feel so strongly about this? And, and can I understand that? And so can I still get to where I need us to go and, and bring them on board? It's a little maneuvering, but it worked a lot. And you know, not everybody is going to agree with each other all the time. And I think as, as you all said, if that's happening, someone's not telling you the truth. You're not, you're not getting the truth from somebody, whether it's, it's the boots on the ground or, or your peers in the office next to you. And so learning to manage public disagreement by remaining professional and, and trying to understand the position that the other person is coming from is going to help you out there. And, and as, as Daelene said, I think at some point, if, if, if you have to take it outside, take it offline, either call a timeout and we're going to get back together at this time in this place, or let's literally leave the room until we can kind of bring the temperature down and discuss it. So we have, we have about 10 minutes left and there was a question that was directed at me that I am going to also direct at all of you that was asking if I have any dream as a leader when, when I have acquired my excellent ultrasound skills after my fellowship, what's my future dream as a leader? And I think for me personally, it just kind of comes back to my priorities. I have rediscovered how much I enjoy clinical medicine, how much I enjoy clinical research and teaching students and residents. And so my plan with my new ultrasound skills, other than maybe seeing some more focus talks at future critical care congresses, my plan is, is to try to expand those skills to other intensivists and specifically internal medicine residents in the army. And there's a lot of potential for point of care ultrasound in military medicine to help us in far forward locations. And so I'm working on building a curriculum for that with some leaders in, in operational medicine. And for me personally, I continue as the critical care medicine consultant to the army surgeon general for another couple of years, which is fantastic. I really talk about an opportunity to both receive mentorship and then to offer mentorship and sponsorship to our military critical care community. That's, that's the leadership position. I'm really excited to continue it. So future leadership positions or future dreams as leaders. Well, I'm coming to the end of my career. Thank you. You have a few years left there, Kristin and then Jess. My dream is to have made a difference while I'm here and to, to be a servant leader for as long as I have been given the privilege and being in this position, this very humbling position to be in. And my thoughts are, I want to go out big and to be very happy with what I've left behind and feel secure that the people behind me are going to continue. But I don't see myself going around and laying in the jungle for the rest of my life. I do see myself being a consultant of some kind because some of the skills that we've gained over time is like flipping pancakes to us and, and might be really beneficial to a young person who's getting started. So I really see myself maybe being a consultant and Chris Farmer gave me some advice as he's just retired last year or so, and he's doing a lot of consulting work. He said, Hey, Dailene, you could do this stuff in your sleep. So I think that's exactly what I'm going to do. That's awesome. I, I dare to say that I think maybe as far as leadership positions go, I sort of feel like I'm in a job where I get to really reach out and touch a lot of people through either teaching or mentoring or clinical work. I, I have a lot of different avenues where I can really touch lives. And so as far as I don't have a dream job or a title that I would seek or, or anything of that sort. But my leadership dream would be to watch my mentees by far exceed wherever I've been or wherever I've done and to be happy and healthy while doing it. That's really where like my priority is like nothing makes me warmer, happier inside to hear good news from a mentor. So for me, much like you just said, Jess, it's, it's looking to have an impact and looking at, at individuals that you hopefully help and grow. One of the things I wish is I wish that we could address more of the burnout and the wellness. And hopefully, you know, as we, as we move on as future leaders, trying to figure out how to help with a lot of that from, from an overall professional standpoint, not just in critical care, although critical care has a higher, but across the whole field of medicine. I think that's something that that's very important and feeling that, that I've had an impact to make people's lives better. Whether that be patients, colleagues, all along those, one of the nice things about clinical medicine and what you're saying, Kristen, is you never wonder at the end of the day, if you made a difference. And I think sometimes in some of the leadership roles, it's a little harder to always say that you made a difference that particular day. Great. Jorge, welcome back. So what were we, kind of the final question that we've gone around the group is what your dream is as a leader. So as you look to the future as a leader, what is your dream personally or professionally, or what would you like to see for those that you lead? Well, I think so to be a leader, we need to be a dreamer. We need to dream. And I think so one of the dreams, what we have at least in our setting is to be able to accomplish and have a full set of intensivists. We just have, we're just building a program. We have some, a few of them that they are taking the position in different units we already built, but we would like to have a more robust program for that. And of course, from a personal point of view, there are many things that we want to accomplish. As I mentioned at the beginning, we are trying to write a series of books on different topics in ICU. And we already have our goal for this year and hopefully we can accomplish those. Great. Okay. So let's go around the horn one last time with anything that you want to sum up with. Let's start with Brenda. So I think you have a lot of great tips here. I think you want to sort of look at this, evaluate it for you personally, decide what you think will most benefit you. All of us are trying to give you some tips. I know it's maybe perhaps a little overwhelming to some, but looking at some of these things that I know I wish I knew at a much more junior level and trying to help you progress, especially in the Society of Critical Care Medicine, it's very open to having everybody participate. So it's a very good society to be able to get involved in. And as you see from Jorge on this call, it's got a very international flavor as well. So a lot of people that need that for promotion, going up the ranks and looking at having international presence as well helps individuals. Great. Pauline? I want to thank everybody on this panel today. It's taught me a lot. I've learned a bunch of tips even here. So even old dogs can learn new tricks. But you know, there's been many great tips that people have offered here. For those of you who may be shying away from leadership, you're thinking maybe I can't do it, look for a mentor, look for someone to give you some encouragement and take that leap of faith because the ones who need to be led might be really benefit from something you have to offer. So I would say just go for it. It's really a it's a wonderful honor to be able to serve other people. Thank you. Jessica? Hi everybody. So I think it's completely like I'm a little in honor to just be on this panel with all of you. So I do genuinely want to thank all of you for allowing me to be a part of hearing everything you guys had to say today. I do think that one thing we didn't talk about today that is leaving my heart a little heavy is that we haven't really addressed the problems of diversity in our in our population nearly enough. And so I would add that onto my dreams for future leadership is to really make a difference as far as getting us to a more equitable place with both respect to who we work with, who we hire, who we interview, who we take care of, and getting both to an equity with respect to providers but also with respect to health care. Great. Jorge? Well I think so if it's an example of inclusive inclusiveness is the Society of Critical Care. And I'm really really thankful because the society has been giving me the opportunity to participate over the years in different areas of leadership. And at the beginning in one of my sessions I usually say that my first time in in the Society of Critical Care in a meeting I was really really a timid to say that I came I'm coming from Belize from a small unit and then to listen to some others say I'm leading a hospital from an ICU for more than 200 beds. But at the end of the day all of us are have a common goal to offer the patients over beds and Society of Critical Care is an open doors and I'm really really thankful for the opportunity over the years. Great. I want to thank you all for joining us for all of the work you put into your presentations and for sharing pieces of yourself with all of us today. I also want to thank the Congress co-chairs for having this session. I hope it's been useful for everybody and then a big thank you to all the SCCM staff and the ETS staff behind the scenes that are making this happen. It is a huge undertaking and so on behalf of all of us thank you all for your hard work behind the scenes. We get to see you in our in our Zoom room but the rest of the attendees generally don't. That's all I have for now. We will continue to monitor the questions in the chat for about the next 24 hours or so. So if you still have questions you can put them there and then as we mentioned networking is not a dirty word so if you have questions individually for us please reach out. We're on social media. We can be found in the SCCM member directory. Find an email send it and and keep the conversation going. So thank you very much. Hope you enjoy the rest of Congress. Thank you. Thank you. Thanks everyone.

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