So welcome to the challenges of caring for those who care, specifically and especially during this pandemic. What we hope to do is to discuss the challenges of caring for healthcare workers during the COVID-19 pandemic and to illuminate an ethical approach to OEM practice during the pandemic. So I am Robert McClellan. I'm a professor emeritus at the Geisel School of Medicine at Dartmouth. And with me today, we've got a couple of people who are from Utah and a couple of people from New Jersey. Jeremy Biggs is the Occupational Environmental Medicine Division Chief and Medical Director of the Occupational Health and Safety for Work Wellness Clinic at the University of Utah Health. And with him comes Margaret Pabst-Battin, who is a distinguished professor of philosophy and an adjunct professor of internal medicine in the program in Medical Ethics and Humanities at the University of Utah School of Medicine. And from the other coast, Rachel Leibu, who is the Medical Director of the Occupational Medicine Services at the Atlantic Health System and a clinical assistant professor at the Sidney Kimmel Medical College at Thomas Jefferson University. And with her comes Peter Bolo, who is a resiliency advocate at the Atlantic Health System and is the chairman of the Department of Psychiatry. None of us have any conflicts to report related to this. So how did the pandemic start out? Do you remember those images and the sounds of people hanging out their apartment windows in New York City and in Italy, you know, banging at times of shift change? The community was deeply appreciating what health care workers were doing to help save lives. But then health care professionals became the villains. On one hand, there were those people who did not trust the science and were so angry that some people were recommending things that thought might save their lives or save their loved ones' lives that they would even beat health care workers up. And then there are those amongst us, a group of people who, for a variety of reasons, might not trust or want vaccines. And they also became villains, although at the beginning they were lauded as heroes. No doubt, even before the pandemic, physicians and other health care providers were physically and emotionally exhausted. It clearly became much worse. And I don't think I have a slide on this, but physically, emotionally, and socially exhausted or isolated, especially at the beginning. Many of the frontline health care workers concerned about bringing COVID home were not living with their loved ones because of that fear and were socially isolated. And health care workers were asked to do even more things already out of moral alignment with many of the things that the health care industry has asked them to do. It became much worse, especially in those areas where crisis standards of care were enacted because of overwhelmed ICUs and emergency rooms. And it's had a real impact on the workforce across the board, not just physicians, but physicians, one in five. This is a very recent report in JAMA Network in 2022. One in five physicians intend to leave practice earlier than they planned. I think 20% of the physician workforce, I mean, that is unbelievable. And the statistics are similar or worse for other health care workers, nurses. Already 20% have quit. It turns out this is obviously devastating for health care workers, but it's also devastating for patients because it's clear that health care workers' health, safety, and well-being matters to patients in terms of quality of care. This publication from the National Safety Council and also work from the Joint Commission looked at the close relationship between health care workers' well-being and quality of care. And as one goes down, the other goes down in cahoots. It was actually a while ago, before the pandemic, that I was privileged to participate in this ACOM position statement about how there was an interaction of health care worker health and safety and patient health and safety in the U.S. health care system. And we came out with a series of recommendations about how we could better leverage OEM strategies for improving patient care through improving worker health. So the bottom line is that OEM clinicians have been responsible for the health and safety and well-being of health care professionals before this and the quality of the care. But as their health, safety, and well-being has been threatened through this pandemic, I am concerned, I don't have the data in front of me today, but that this has impacted even more so the quality of care that they were able to provide during the pandemic. So what we are going to do today is to have each of these panelists present their core message relatively briefly, because I think what will be most interesting is talking about this. We all have our own perspective on this, and rather than standing up and just kind of telling you our personal stories related to this, I think it's going to be much more interesting to talk amongst ourselves about this. So after a 5 to 10 minute-ish presentation, I'm going to ask one or more of the panelists to comment and question after each presenter, and then we're going to go to you and ask the same and see what kind of perspectives you may have. Please do come forward to the mic, because we do have online folks who won't be able to hear what you have to say otherwise. So with that, I'm going to turn it over to our first speaker, Jeremy Biggs. All right. Good afternoon. So I, like I said, I'm at the University of Utah, been doing occupational medicine there for a while, and have been talking with the C-suite people for many, many years about different health and safety issues with health care workers. One thing that I think came to light more when the pandemic hit is kind of what we were talking about just a few minutes ago, was not just the physical safety, making sure they're cleared for respirator use and fit tested, which are obviously very important things and so forth, but it was also a feeling of, do you feel safe at work, right? We mentioned at first, when there was a little bit more public support of health care workers, the physical safety wasn't as big of a deal, but there were, I'm sure in your guys' institutions as well, we had quite a few providers that didn't know what to do when going home. They felt like they were putting their family, their children, their elderly parents, whomever, at great risk for going home, and so some went to hotels, some got a hotel, or some separated themselves, saying, I'm only going to go into the basement, and I'm going to take off all my clothes, I'm going to throw them away, and I mean, there was a lot of mental health stresses that I think as health care workers, we often have had in some form or another, but have never really been discussed or recognized, because it wasn't as obvious. So the stresses and feeling safe as a health care worker, again, there's a lot of physical components to that, but I think the pandemic has allowed us to think a little bit more about the emotional and intellectual safety of health care workers. And then it was important, too, as the C-suite guys and girls who I was working with, what their roles are in that, because in the past, they didn't feel like they had much of a role. They figured health care providers are professionals, they're adults, they can take care of themselves, if they have problems, they'll let us know, and that was kind of the general idea and feeling that you typically got from them. But then this pandemic came, and luckily, I worked with some pretty good people there, and they recognized that we needed to do a little bit more than what we've done in the past. And then, of course, there are lots of studies and different opinion pieces that say when health care workers or any worker is stressed and has anxiety and doesn't sleep well, they're going to make more mistakes, more mistakes in patient care, but also more mistakes that will cause them physical harm as well. So I'm sure you all remember these types of headlines as well. So again, we're coming to work, we don't really understand things extremely well, and then you get these reports of, like, there's no more PPE anyway, so, you know, good luck. You're going to work with this virus that we don't know a ton of information about. We don't know if, you know, you're going to die from it or not. We're not exactly sure how it's spread for sure, you know, is it droplets, is it aerosols a combination of the two? And if you come into work, we may or may not have what you need to keep yourself safe, right? So that added stress, of course, was pretty significant. And the thing that I think that bugged most of us the most was this kind of feeling, right? Every time you came into work, there was a new policy, there was a new something, because we learned something new the day before, or we no longer have that PPE, so we have to change to something different. And so there's a whole new policy. I use this slide a lot during the pandemic, just because it really was, that's how we all felt, I think, on a fairly regular basis. So I put this slide up here just to kind of give you an idea. What we ended up doing to try to help address this a little bit was increase the communication with all of our healthcare providers on a daily basis. And what we would do is multiple things, but one of the things we would do, because, again, PPE was one of those big, scary things during the first parts of the pandemic, not knowing what we would have, I would get up every morning to the institution, and we would go through kind of the things we use the most and say, don't worry, this is, you know, basically if you look at the end, this is how many days on hand. If we're using them the way we're currently using them, and we don't get any more, we have at least 61 days left of this PPE item. And what I got feedback was at least they didn't have to worry about, like, next day, next shift, if they would have PPE, because they knew that at least we had 60 days or 30 days or whatever. So that was one less stress that they had to worry about. And again, when we were kind of that Chris Farley stage, one less stress can make a big difference. Also another thing that I did is I explained to them on a regular basis why we were doing what we were doing, even if they didn't necessarily care or understand all the science behind it. So this was another example. Like, when people were like, why do I have to get fit tested, and what's the difference between this one and that one, and what are we doing for? Well, then I would take time and go through all, this is why we're doing what we're doing, and this is what it means. Again, they may forget it tomorrow, but at least that day, they felt like we were trying to teach them everything we could and give them all the information that we had. And again, the feedback was that they felt a little bit better. And then again, we would talk about this on a regular basis. We recognized that every day there was a new hole in our safety because we would learn something more or different about the virus. And we acknowledged that, and we acknowledged that we were doing our very best to keep up on everything and have all the experts and taking all the advice, and then that we would do something different as much as quickly and as much availability we had to do so, we would do that. And again, we were just trying to lessen the stress, keep our people safe, keep them at work, but keep them safe while they were at work. So that's my five-minute presentation. Anyone from the panel have any comments or questions? I'm going to comment. I love this presentation, and I like your slides. And I think that I love how you focus on the safety, like the physical safety of the workers. You touch a bit on their mental well-being, but, I mean, so important to look at the mental well-being of folks as we go along here because it has such a huge impact on retention, recruitment, satisfaction, engagement, work-life balance, et cetera, and so it sets the stage for that. So this is sort of the safety and well-being concerns have really tipped us over into that arena, which is really important at engaging workforces, not only in healthcare, but in all industries. Thanks. Yeah, of course. And, you know, something we did was people who are better qualified than me, like you, would also get up and do, you know, wellness, mental wellness discussions on a regular basis during the pandemic as well. I can definitely relate to all the things that you're saying because it really was a huge challenge, and it was a daily challenge. We had things changing on a daily basis almost, and this is in comparison to changing policies maybe once or twice a year. There may be a change that you would want to add, and now it came that it was a daily occurrence, and we were having daily huddles with our team. We had a whole exposure team that we put together to help keep our employees safe so that they could get to the bedside as quickly as possible, but not coming to work infected because if we couldn't supply the workforce, we wouldn't be able to safely take care of our patients. So some of this is then, and here we are now where the public perception, at least to some degree, is this is over, right? We're going back to normal. How does that affect what you have to say here? Do you relax policies? Do you think we're being short, well, I know we're being short-sighted, but that is. So yeah, so I don't think we relax policies. I think what we're doing now is we're, again, doing our very best to keep everybody informed with the best information we have. Luckily it's a little bit slower. I mean, I still have to take the fire hose of information for COVID, right? I mean, there's papers every day and a bunch of information every single day. But the biggest key is we are focusing more on less on like the PPE wellness side of things because again, that's a little bit calmer and we have better supplies and things, but we're focusing still really robustly on more of that mental health. And do you feel safe in your job? Not just physical safety, which we're still focusing on as well, but also mentally, do you feel safe? Because again, we've suffered the same thing as everybody else where we've lost a huge amount of our healthcare providers because they didn't feel appreciated or they didn't feel safe or they didn't feel like we were caring enough. So what we're focusing on is more of that than we even did during the pandemic, the beginnings of the pandemic, I should say. I'm going to make it really easy for someone to say something. My name is Shlomo Moshe, I'm from Israel, and I wondered, we saw yesterday the figures about death among healthcare workers, about 1,400 healthcare workers died. Now in the beginning, we felt we are safe, but then people died, not just infected. How did this occasion impact healthcare workers in your surround? Yeah, so I think especially at the beginning, when we didn't have the vaccinations available and we were still trying to understand transmission and the impact of infection in a different population, it was a huge, huge stress when we would hear of healthcare workers who died from or with COVID infection. So what we ended up doing is having, of course, we had a crisis line, right, that was dedicated specifically to COVID. So I work in the work wellness clinic for the hospital and clinics. And we ended up staffing, you know, bringing in staff that were more qualified again than myself to address these things. And it basically had a hotline of questions, even like, you know, my cousin died of COVID. What does that mean? And we would try to do our best to have information, but then just listen too, because sometimes we didn't have the answers, especially in the beginning, as to what exactly was going on and why this person died and this person didn't die. I mean, we had risk factors and things, of course, right. But so again, I think the biggest thing was, one, listening. We would allow them to have a venue to discuss and then trying to share the information the best we could and then just supporting them is what we ended up doing. My name is Blake Lawless, and I had a question about the 20 percent of physicians that are purported to want to leave the profession. How as occupational medicine doctors can we respond to those people to maybe keep them in the fold, maybe keep practicing, because it seems like a positive feedback loop could happen to where if those 20 percent leave, the 80 percent that are left are going to be overworked and therefore want to leave, too. That's true. I think we are typically uniquely positioned within our organizations to, you know, as providing clinical care, but also to provide advice to administration. Right. Because a lot of times we do that dual role fairly regularly. So I think that's the time where we take that administrative role that we typically do and try to address that 20 percent concerns, right. Like, is it burnout? Is it because they feel like they're working hard, you know, but not too hard, but not getting paid enough? Where is it? Where are the concerns? And work with a team to figure out those concerns and try to prevent all of them from leaving. We're not going to prevent all of them, but we try to prevent all of them from leaving. And then I think at that point, once we learn more, even when they leave, then at least we'll be able to start addressing that with the remaining health care providers before they decide to leave. Right. But I think, again, the biggest part is just trying to figure out why exactly, because sometimes they'll say something on a survey, but that's not really the reason. Right. So if you're not familiar with the National Academy of Medicine's website on the Action Collaborative to Improve Clinician Wellbeing, they had that consensus study that had a variety of things to do, but they also had an update of what to do during the pandemic or what we've learned that can really be helpful. So they have a number of really good toolkits and ideas and specific things that can be done from an OEM perspective, but typically through the superstructure, you know, is usually necessary to get people what they need. Bob, can I say something just quickly on that point, Bob? I just want to also jump in. The AMA just published their five actionable to-do list for health systems over the next three months. They released that in the end of March, and some of them really sound quite simple, and I think they're really important and pertinent to this. The first one was to try to offload as much stress as you can on your clinicians, to think about dialing back some of your goals, even like quality goals, patient satisfaction goals. Maybe it's not the time to ramp up and really put extra pressure on people who need a time for recuperation. They also suggest having beyond a traditional EAP and trying to provide some EAP services with clinicians who are adept at or have some additional training or experience working with people in health care to help them, you know, prevail through. They had a few other very good suggestions. I'd look that up if I were you. Well, I can stay here. OK. Is that OK? Can you see me? Good. So I'm going to talk about an issue that presented itself at the beginning of this situation about triage. Right. It's something we haven't talked about very much recently because we have come to think that it's not necessary or won't be necessary. It was certainly much discussed at the beginning of this pandemic and also the various organizations, both system-wide institutional prioritization schemes, states, counties, individual hospital systems, even individual clinicians were forced to think about triage. So it is important to keep thinking about this because, after all, it could happen again. Now, it's important to be clear that this isn't about futile care where the chance of survival for one party is small or unnecessary care. This is about care where two patients are essentially equally qualified, equally likely to survive with the treatment and much more likely to die without it. That was the perceived situation at the beginning of this extended history we have over the past couple of years. And while we think it's not relevant, it is not gone either. So there were situations reported from Italy at the very beginning of the early days. You remember all those awful scenes we saw from Italian hospitals? Doctors were forced to make these decisions right on the spot. It was discussed extensively in the US. I'm not aware of any reports of actual triage protocols being put into action. But as far as I know, every state has got triage protocols prepared, and so do major healthcare systems and everybody else. So they're there. We need to think about them. So here's a little test question, and it is deliberately, I think, a little bit not PC, but let's just see, but on purpose. So imagine two patients in adjacent beds. They're both 68. They're both female. They both grew up in poverty, and they each had a mother who worked as a housemaid. They're both black. They're both overweight. And each one, this would be the discussion at the beginning of the pandemic, needs a ventilator, but there's only one available. This is the classic triage situation. To which one do you give the vent or other healthcare? How do you choose? Got any ideas? Speak up. How would you choose? They're the same on every axis, on every factor here. Sorry, I'm not. This is a session where the people who are furthest back are the rottenest eggs. Those people who come forward. Sorry, I'm the rottenest. So how would you choose? I was just saying, like, do they have any comorbid conditions, like diabetes? Like, look at their medical record to see who is more likely to survive. Let's just assume that they're almost, they're exactly the same. If one has diabetes, so does the other one, and so on. Like, how long have they been sick? Well, let's, of course, the point in triage is you're choosing between equally qualified candidates for whatever the treatment is. This is not always the case in real life, but when we're thinking as, I feel it's philosophy, so we're always thinking in abstract terms, that's the challenge. Yes, would you choose? Would you ask each patient what their preference, I mean, one patient may not want to be intubated and say, no way. Right, right. That would be a question I would ask. Let's ask them. You understand that we'd have to intubate you to give you ventilator treatment. Do you want that? Yes. You have to understand we'd need to intubate you to give you ventilator treatment. Do you want that? Yes, says the other one. Okay, so now they're both the same. That's the kind of problem, and for any factor you might suggest. Are there any other ways? Yes. I want to give you an answer from real life. In real life, it depends who is the family. If the family which surrounds the patient is big and shouts enough, she will get the treatment. If the patient is alone, probably she won't get. Thank you for saying that. We like never to say it out loud, but we all know it's true, right? So we're trying to talk about justice in triage management here, and we recognize that perhaps things are not fully just. So these triage policies that are now available have two purposes, to prevent bias and favoritism and other kinds of abuse, and to protect bedside clinicians from sometimes agonizingly hard choices. I think virtually all the triage policies I'm aware of form, they designate a committee other than the bedside clinician for making these decisions. And so the question here is, does this make hard choices even harder? So we're thinking about the things that are difficult for healthcare providers, and this is one that may be a factor and doesn't get talked about. So these don't tell us how to decide. They put it off onto a committee, but we have to remember that these decisions about not who gets the vent, but also who doesn't and dies. So here's the problem, right? Where in triage situations like this, there's one party that gets the treatment and the other one is triaged out. So we want to think carefully, although we'll do it very quickly here, about what you ought to do about what you ought to provide to the one who is the loser in the triage competition. Well, here, at least four kinds of things, rights to information, rights to personal choice. Let's just look at this so quickly. Rights to information, rights to personal choice, rights to try, you know, and so on. Rights to communication. This was very prominent early in the pandemic when family members were not allowed to visit. People showed up in ERs with their cell phones, but with no charger cord, so they couldn't maintain the charges on their cell phones. They couldn't receive visitors, even from, say, their own religious advisor, their attorney, any such parties that they might want to have, right? All of these things are the things we need to think about for the one who doesn't win the game. And finally, there are issues about a right to a humane death. Remember, we're assuming, in this case, that the triage situation is severe enough so one gets the treatment, whatever it is. It might be ECMO. It might be whatever the current most effective treatment is. And the other one is at risk of death. How might that death go? Should that party still be entitled to palliative care? Do we have the resources for that? What about physician aid in dying? This is legal now in this country, in states, in 10 states, in the District of Columbia, and covers almost 25% of the US population where this is legal. Should this have been made available to people who lost in this deal? And finally, the no discharge without supportive or palliative care seems like a reasonable demand. So let's go back to our two patients, right? How do you choose, right? What if one is a hardworking, underpaid, we used to say downtrodden, domestic housemaid, just like her mother? Oops, we forgot something here. And the other one is Oprah Winfrey. Now you see that this little problem trades on every stereotype and distortion, right? But all these factors are relevant, except Oprah isn't overweight anymore, but that's a minor technicality. How do you decide between these two candidates who are assumed to be otherwise equal in every factor that we can discover? Is it about equality or deprivation or social standing or deservingness or contributions to societal welfare? Or what? The point is not to try to answer this ethical dilemma, and I think it is a dilemma. Every triage situation where the contestants are equal is a dilemma. But to point out how difficult this can be for individual clinicians at the bedside, for the institutional committees that are formulating policies for large social triage schemas that might need to be brought into play, but I think especially for the clinicians. And what makes it particularly difficult is when the one that gets triaged out is, in the phrase of one observer, kicked to the curb. So I think this is something that we need to think carefully about. There's very little discussion of what's done for the parties that lose in triage situation, and relevant to this discussion here, especially relevant to the way in which displacing decision-making onto policies developed by a committee may result in truly painful ways of dictating the behavior of individual clinicians. Thanks. I think it's really morally important to think about these things. And even though we may seem to be on the downward slide from this pandemic, there surely will be others coming along. So the question is, in our role, generally not at the bedside making, needing to make this kind of decision, but responsible for that in that committee or the person at the bedside. And I will say, even when it's, obviously when it's a committee making this decision, there are people at the bedside who have a relationship with that patient. And so how do we, in OCMED, care for those people within our role? So ideas. Yeah, I don't know if this is speaking exactly to what you're talking about, Bob, but it just seemed to me that the moral distress of the clinician at the bedside delivering somebody else's decision, especially if they're not in agreement with it, is much greater and it's a more fraught situation than having grappled with the decision oneself if you're administering the treatment at the bedside or not. It's also worth remembering that the official rationale for having a committee do it is to protect the clinician from hard decisions. And the question here is, is it actually paradoxically the other way around? Having the decision displaced and made abstractly somewhere else, is that harder for the clinician? So there is a difference between what's legal and what's moral, right? And I suspect that this protects the individual clinician legally, but to your point, maybe not so much morally as far as the moral injury. I would say part of our role is, again, to recognize the mental safety of both the committee members but also the clinician at the bedside. So as, again, as we're part of this process, like you said, most likely not the ones at the bedside doing the ICU care and making this decision, we need to make sure that there's resources available for all those that are involved in this to get through it. Because, like you said, it's gonna be individual. I think some people will feel relieved that they don't have to make that choice and they can blame it on somebody else. It helps them feel better. And then there's gonna be other people who will be very frustrated. So we have to recognize all of that and then figure out resources that the institution has for those individuals. So are folks familiar with Schwartz Rounds? That sounds... So Schwartz Rounds is held in many institutions. Are they in yours as well? But they're opportunities for a clinical team to come together, usually after an event, I think, maybe in the process, but I think it's usually after the event, to kind of talk about what it has felt like and how they could better support each other and family members in the context of this event. And I think, I mean, I've participated in a number. I think they're very emotionally powerful and healing. And so if you don't know about Schwartz Rounds, and you are in a setting where you might be faced with caring for people, make all kinds, it may not be life and death. It could be other kinds of reproductive health decisions or whatever, that Schwartz Rounds can be a really useful tool that's available in many hospital settings or could be brought into your hospital setting. Rachel, you wanted to say something? Yeah, I just wanted to go back to the point of having the decision taken away from the healthcare provider. We have an ethics team and the nurse ethicist was very involved in these situations where there was at one point, people were not doing CPR on COVID patients. And the decision of who would have CPR and who wouldn't was not done by the physician. It was done by the committee. And there were some physicians who were very vocal and upset about not being able to make that decision for their patient. So there are situations where, although it's taken out of the hands of the clinician, there are gonna be some clinicians that are not happy about that at all. And that is what they found. And the nurse ethicist got involved and had to diffuse the situation. So we see what the tensions are between the physicians wanting to make that decision for their own patients, but of course you want to favor your own patients against other competitors for the same resource. So there's that problem. And as you rightly point out, I think different physicians will experience this in different ways, different clinicians, different nurses, different everybody. These are hard, hard questions and I don't think we have good answers for them yet. One thing that you didn't mention, at least if you did, I missed it, was the idea of ROI. So like in the distributive justice, who's more likely to benefit? One of the audience members was talking about that. Who's more likely to respond? I know you had people who were totally equal, but it seemed like that in healthcare comes up a lot. Who's most likely to benefit from a treatment, all else being equal? I think I missed a slide and if I can find it, I will show it to you or maybe it's dropped out somewhere. Are there? Keep talking about something. Oh, it's gone. Any thoughts how we could help the folks on the committee or the person at the bedside from an occupational medicine perspective? I'm actually okay with silence for a while. I think engaging the people at the bedside is one idea. So if you're gonna set up a committee that's going to make these decisions, I think they're frequently are populated by some clinicians but obviously can't have the team at every bedside. You're really quiet because you'd think this would be a problem that would concern everybody who's involved in healthcare in pretty much any way where there are triage situations. There's one. Thank you. Sharing a somewhat similar situation, not exactly the same, but in my health department, we confronted quite regularly the need to make a decision to medically evacuate a person suffering from critical COVID. To a center of higher care, which was one hugely challenging, you can imagine flying an infected COVID person to another country. But through working with WHO and others, we were able actually to do that. But each episode of that costs probably $150,000 or more. So there's a huge financial decision. And part of it then is, is the person actually likely to one survive the trip and benefit from the care. And there we did use a committee approach, but it wasn't either or. The treating physician was part of the group and there was a general discussion. And of course, the treating physician's opinion was strongly considered, but was not the ultimate decision. And the trigger for the action was made by the committee. So in some senses, it took the burden off the treating physician if the decision was no, and there was some protection then from potential consequences and criticism of family, et cetera, et cetera. But as you said, these things are not easy. But they had the opportunity to advocate, which is really important for clinicians. So bravo, that's a great example. And it's important to be reminded of the fact that triage or these kinds of decisions can occur in many different ways. It's not just about ventilators. All right, well, Noreen, yeah. I think also mental health professionals should be involved in this process. Either evaluating both patients and evaluating the situations of the caregivers. And maybe their input could help to a certain extent. But more important is, yeah, do we check the boxes? They're both equal, they both have equal risks. Do we check the box? Have we looked in the community? In other words, can we transfer the patient to a community hospital from a major hospital that have the capacity? I mean, I know when ambulances pick up patients, they try to find out which hospitals have beds. So it's not just one hospital that should be taken into consideration, but what's available in the community. And do we transfer patients to where there's capacity? That's of course, it's assuming that there is capacity still available somewhere. Right. And there's always gonna be some relative access, greater access in one place and another even if it's awful everywhere. One point I want to remind, we are in a preventive field, occupational medicine, public health. And actually we didn't talk about prevention of ethical conflicts. I mean, if the country is prepared for a situation like this, the ethical conflicts would not arise because you have enough places. When you don't have staff, when you don't have beds, when the stakeholders do not believe the medical healthcare workers and don't give enough budget and tools to fight an epidemic, it's clear that this situation happens. Now in Israel, where I come from, the health system is prepared for war all the time. So the open department in an underground parking, which were built in case of more injured patients than expected. And that's how they solved the problem of places. And they had enough staff. But in Italy, there is a grown-up population in higher percent than the average accepted in Europe, and they could not face the amount of people who came. That's why the ethical and the conflicts and the triage problem, because they don't have enough beds. So I think the main lesson is do not come to a place where you have ethical conflicts. Be prepared in advance, and you won't have to conflict with such a description as is told. And you're talking about the rich world, right? Italy is not a poor country. Right. What about the rest of the world? I don't know if we have anyone from the military here, but I understand that given all of the problems, the predictable problems with PTSD, there are some efforts to harden recruits before they're going into battle. I'm not sure what all the resilience tricks are, but is there anyone from the military that has any experience? And I'm curious, and I don't know whether or not... And hardening is the wrong word, because you don't want to harden people. But you want to provide them, I think, some preparation, because obviously every one of us who takes care of patients runs into ethical issues of various types. And how do you deal with those ethical conflicts? And so I do believe that there might be someone who's actually looked into whether or not there is a approach that helps people prepare so that they're not so harmed in this kind of situation. I think the best thing is being informed, so you take Margaret's class, so that you understand ethical decision-making. That's a big part of it, I think, is being informed and know... So you've got one minute, Margaret, to give us your class. The slide that's missing, and I can't find it in this deck, it's dropped out somewhere, was looking at the types of criteria, of prioritisation schemes, and whether they use patient or person randomising strategies, like first come, first serve, or, you know, lotteries. Any person... They're called person-neutral schemes. So that's one way you could solve this. Well, which one came in the door first? Or which one... We'll flip a coin between these two, right? And the others that are much more controversial and more difficult to apply, but are, I think, innately more attractive to people, this doesn't mean they're fairer, are things like past deprivation. So notice in this example, these are both daughters of domestic, hard-working, downtrodden, is the old phrase, housemaids. That's the way they were described. We know that picture. We think that's a picture of deprivation, and that should somehow be compensated for. There are other features about past social contribution, expected future social contribution, responsibilities to other parties, including one's children, spouse, co-workers, some kind of important project that's being worked on. We intuitively take into consideration all those things, but it makes this kind of choice even harder. So when the choice is between somebody who is a housemaid, that was the term, and Oprah Winfrey, as public a figure who has done more for the popular good, I think, than many, many people, who is, of course, also able to pay, that's sometimes a consideration. She is larger on all of those indices and hence would be thought to be more deserving, but that doesn't take away the fact that these two people are similar in every other relevant respect. So it doesn't make it easier. It just shows our own biases when we think about this problem. Can you imagine flipping a coin between Oprah Winfrey and this other person? I don't think those mechanistic models work at all. I think they're very unsatisfying and it's just a cop-out. We use them all the time, yeah. But especially when something of this gravity. I just have to say, and I know you mentioned, this is very bias-laden and judgment-laden, but of course some folks growing up with moms who are housekeepers are more resilient and maybe better and more poised for success and accomplishing more in the world than somebody who has grown up with a silver spoon. We're going to have one more before we move on. Your question in the red striped shirt made me think. I think we also have to step back and ask why we were unprepared for making battlefield-style triage decisions. We built a system that operates on very lean margins. I remember friends saying, oh, the ICUs are 85% full, but they're meant to be 85% full. We operate without lots of flex capacity. There are no underground places to rapidly expand in our health care capacity. So don't lose sight, I think, of the fact that the scarcity of these resources is not some sort of accident. And the analogy between military battlefield situations and this kind of health care situation isn't actually very close. At least the original motivation of triage in battlefield situations is who can we get back into fighting condition? And that's, of course, not the worst off. That's, of course, not people with other social advantages. Who can we restore to military effectiveness? Good afternoon, everybody. I want to talk about moral distress and resilience during COVID-19. And hopefully I won't cause too much moral distress with you. But luckily at the end of the discussion, we'll be discussing tools on how to deal with moral distress. So we'll start with some definitions. There are many definitions of moral resilience. It could be to be good and prove one's integrity and character under conditions of risk. It could be the ability to cope with crisis situations and particularly crisis related to moral principles. And there are many, many other definitions. In terms of moral distress, that is defined as knowing the right thing to do but not being able to do it due to some kind of external constraints. There are 6 domains of moral resilience listed on this slide. I'm not going to read all of them to you, but a few I would like to point out is personal integrity and relational integrity, how we relate to one another and how that relational integrity is very tied to trust. And that is a very, very important thing to keep in mind for both the organization, for your fellow coworkers, and for yourself and your family. Also there's buoyancy and moral efficacy as well as the others. Now I want to discuss a few cases of moral distress that were caused by some situations in our facility. The first case was a DNR-DNI reversal. It was a retired physician of advanced age who had many comorbidities and they were admitted to the ICU. They initially were admitted as DNR-DNI by their family. Three of the family members were physicians, but they changed their minds after they were watching their loved one decompensate over Zoom calls. It was very challenging when we had to restrict visitors and people were only able to see their family members remotely. The patient had a prolonged hospital course which escalated to pressers and eventually they allowed one of the sons to come in and see him after this patient being on several weeks of organ support with no improvement. But despite that, the aggressive intervention continued. The hospitalist called the family and informed them that they couldn't do CPR because he was dying and the family wanted everything done. So it was a huge relief to the staff when this patient eventually did pass away because there was some question as how much effort do you put into a patient who is decompensating and has no real hope for recovery. So that's case one. Case two is a case of delayed care and it involved a 14-year-old girl who was an only child who developed unexplained weight loss and apathy. So her mother made a telemedicine visit because you couldn't get a visit in a doctor's office initially during the COVID pandemic and well into it. And the practitioner ordered blood work, but because the girl was afraid of needles, her mother didn't send her for blood work. And then, unfortunately, the child arrested at home because she had new-onset type 1 diabetes. The EMTs were called. They came and they were able to obtain spontaneous circulation, but unfortunately the child had an oxygen brain injury which led to brain death. The parents were divorced and the mother projected a lot of anger onto the health care team. The staff had a multidisciplinary meeting with each other and then with the parents to discuss next steps about evaluation for brain death. And the third case, they're all tragic, but this one I think is very tragic. This was a 32-year-old female who was admitted to the hospital in labor. She had initially planned for a home delivery. Her husband, unfortunately, had had COVID the week before she went into labor, and the woman herself had COVID when the midwife came to her home. And she had the woman sent to the hospital because she could not deliver this woman in active labor with COVID. So the woman delivered a healthy child. She was desaturating during her delivery to the 60s, and it was suggested that she be intubated. However, she refused intubation initially, and despite having worsening respiratory status for three days, she continually refused intubation despite her family pleading with her to be intubated. Finally, she did agree to intubation when one of the residents sat with her and spoke with her for a while, but then a few hours later when they came to intubate her, she decided she did not want to be intubated again. And so they called in psychiatry who determined that she had capacity to make that decision, and that was followed by a palliative care consult who also concurred with the psychiatrist's decision. And despite the family pleading with her again over Zoom, you know, they weren't in there with her, she would not relent, and she died four days after giving birth. So all of these are tragic situations that we all have to think about ways that we can maintain our own resilience because these are very distressing situations. Now these also are distressing situations, maybe not quite as acute as those, but there were a lot of concerns pre-vaccination. There was a lot of distress and fear among personnel because of exposure to the virus with no cure and no means of prevention. There were very young nurses who expressed concern about making out their wills, and they promised each other They made them promise what they would and wouldn't do and who would do procedures to them, such as inserting a Foley catheter. And then there were health care workers, and this was mentioned previously, who isolated themselves from their families to reduce the risk of spreading the virus at home. One of our ICU nurses sent her sons to live with their father, and she didn't see them for four months. So there was a lot of isolation amongst families during this unfortunate period. Some of the challenges in occupational medicine specifically were health care workers reporting to work with COVID-like symptoms. Does that sound familiar to anyone? And those refusing COVID vaccination. Now once COVID vaccine became mandatory, that became less of a situation, although we still had to deal with those team members who were objecting on religious or ethical grounds to vaccination. And our facility put together a committee that would review these requests and equitably, as equitably as you can, and determine whether the request would be granted or not. And if it was, then the team members would need to be antigen tested. And despite the fact that some team members were granted a religious exemption, they would refuse to have antigen testing, but they couldn't refuse. That was a requirement of being granted an exemption. We also had health care personnel who insisted on going to work prior to the end of the communicability period. We didn't allow that, and we have an exposure team that has extensive conversations with employees like this to ensure that they are not coming back to work when they're still contagious. There were practitioners in the hospital or in the clinic settings who wouldn't enter COVID patient rooms, and that caused a lot of conflict between those who wouldn't enter and they may look through the window and those practitioners who actually physically went into the room. And then, this was mentioned previously, but the emotional distress over the whiplash of initially being declared heroes and then being on the receiving end of anger and disbelief that was perpetuated by misinformation. And there's a lot of anger and incivility targeted toward health care providers. So before I get into the tools for dealing with moral distress, I wanted to talk a little bit about how you mitigate moral distress. These are some of the tools that we used in our organization, but I'd like to discuss just a general overview of what you can do. So to mitigate your moral distress, people need to seek support and continue to emphasize self-care, and they need to learn to care for themselves so that they can come out at the other end of the situation intact. But to do this, they have to determine what they're experiencing because they could be experiencing moral distress, they could be experiencing burnout, or they could be experiencing compassion fatigue. And each one of these situations requires a different strategy. So I'm going to focus, though, on tools for dealing with moral distress specifically. So when you're experiencing moral distress, you need to identify the causes by recognizing the situations and the factors that contribute to it. And you have to gauge the severity. What I mean by gauge is rate it. There are rating scales. So on a severity of 1 to 10, how much distress are you experiencing? And then once you have this awareness, you need to take action by looking at what personal resources, what unit resources are available at work, and what organizational resources are available to you. And there is a pamphlet on moral distress that's very, very helpful, recognizing and addressing moral distress that is put out by the American Association of Critical Care Nurses, and it categorizes all the different available tools. I know this is too small for you to see, but I'm going to point out some of the important points that they make in the different categories. So for self-treatment, they say recognize the symptoms of distress, connect with others for validation and support, identify involved parties who can help you, also participate in professional development such as palliative care or ethics education, and seek help from clinical leaders and or employee assistance programs. And on individual units, one of the suggestions was to pause after every patient death, conduct resilience rounds, create a mentoring program for new staff to help them get through the situation, identify ethics champions for peer support, recognize situations that frequently cause distress, and establish a committee to address common sources of distress. And then organizationally, they suggest promoting actions that improve the work environment, offering resources to support health care teams such as moral distress or ethics consultation services, and provide training on critical debriefing, resilience, and skilled communication, as well as adopting a zero tolerance policy on bullying and violence and building programs that promote the well-being of the entire health care team. Now, at our organization, we did a lot of these things. One thing that was very useful to staff on the palliative care unit was that they did a pilot study where every patient that was admitted, they would get the family to write a synopsis of the patient, who is this person, so that the staff knew who they were caring for because a lot of these people were not able to speak or tell them who they were. So it gave them a human connection and a more personal connection with the patient they were caring for, and I think that's really, really important when you're dealing with a patient that can't communicate with you. Bob mentioned Schwartz rounds. We have Schwartz rounds around this. We had a nurse ethicist who would make rounds on the critical care units and support the staff. They had creative writing sessions for nurses and other staff. They did formal debriefing. They had informal rounds, and, of course, we had EAPs, and then Dr. Bolo, of course, spearheaded a huge initiative on well-being of health care workers during COVID, and that is, I believe, the last slide. Oh, no, key characteristics of moral resilience. So here are some important points about moral resilience that are put together by Cinder Rushton. I don't know if anybody's ever heard of her. I never heard of her before preparing this talk, but she is a huge advocate and well-known proponent of moral resilience, and in order to cultivate moral resilience, you should have mindfulness to support focus and clarity of mind, develop self-awareness and insight. I'm not going to read all of these, of course, but the last one I think is very important, preserving one's integrity as well as the integrity of the team and others. And that's all I have to say for now about moral resilience and distress. Does anybody have any questions or any comments? Now it's on. Thank you. So I love the point that you made about how the staff engaged the family, oftentimes who weren't able to be at the bedside as much as they like, and the productive work of sort of describing a biography of the person that then was helpful to the staff to create an identity of the person that they were taking care of in the bed, many of whom weren't able to converse because of their pulmonary distress. And it just speaks to the importance of cherishing and developing that human connection. This is why people are in health care at the bedside. So kudos on that and much more helpful than trying to objectify it onto a scale of distress, which is not humanizing in particular. So that's great. There is a question in the chat, but it relates to triage. So it says, Above relates to ethical challenges facing caregivers in triage. Seems like this would be a great topic for group sessions with individuals facing both triage results for their patients. Is there evidence of survival guilt by proxy in caregivers whose patients gain the scarce resources? And then there was one other comment regarding debriefing. There is some literature suggesting that critical incident distress debriefing can re-traumatize first responders? Can you speak to how this can be monitored and avoided? I'm gonna talk a little bit about that. Okay, good. So it's a good segue. I was just saying, when we come up with these ideas like champions and mentors and things, but we also are dealing a lot with burnout, right? Like our employees and our healthcare centers are just taxed out. So how do we balance that? Like here, you're also gonna be a champion and you're also going to lead this group and you're gonna go to this extra discussion after work today and help you. But at the same time, we're getting feedback that's saying, I'm so burnt out, I can't be here another minute. But I think that being involved in that can also be therapeutic. So I know that you could say you're so burnt out like I did before I gave this talk, but actually getting involved and learning about burnout and resilience helped me. And I do think that it can help people despite the fact that they may feel that they're not able to go on and take another minute of being at work. It's a good point, but you can know your audience and there are some people who want more and they feel honored by that and really engaged, but you're right, it's a limited resource. Sure. Okay, okay, great. So Rachel and I are from the same health system. I'm gonna use this. And so I'm centered at a 450-bed general hospital in northern New Jersey, and it's part of a five-hospital system that has about 18,000 employees. And I started out with Bob's very good suggestion with this slide first. In July of 2020, we took on the AMA's COVID wellbeing survey that they were encouraging health systems to use to try to get a handle on how their clinicians were doing at the bedside in terms of burnout and moving forward. So we had a response from about 500 physicians and advanced practice clinicians at the facility, and results were very interesting. So the vast majority said that they felt modest or high levels of stress, I think was not surprising to me. Three quarters felt anxious or depressed, also not surprising, but very surprising and actually made me feel a little bit good for the respondents here, that three quarters felt increased sense of purpose with their activities, and the vast majority felt valued by our organization, which I think speaks toward very strong administration that partnered with the clinicians in deciding how to move forward with managing the pandemic, and that was very much appreciated. It scared me to see that 5% had experienced thoughts about suicide during the prior months, but when I drilled down a bit more, I saw that in most surveys of physicians, you'll usually get somewhere between four and 7% on that answer, even at any given time. And physicians do have a higher rate of suicide. Those were thoughts about suicide, even if the thought popped into your head. I did send a correspondence, however, about that to the team, letting them know what the resources were if they were experiencing any depressive symptoms. So at Atlantic Health, we have our own custom definition of resiliency, because it's a word that's very abstract, and people are uncertain of what you're speaking about, so it really has to do with bouncing back and growing through challenges, and enjoying what you do, and who you do it with, and why you do it. And we developed, actually adapted, a framework for resilience. Some may recognize some of these thoughts from Stanford. With three domains of resiliency, because resiliency is not all about just making yourself ready to be at work. It's more complex than that, and a bit layered. So there is that in strengthening ourselves, but there's also being more effective together. Things like making sure that EHR can be used easily by people, that workflows are efficient. And then finally, very important, is that the whole organization, starting with the leadership, is nurturing and buying into the fact that we need to nurture a culture of well-being amongst everybody in the organization. And then to highlight the values of empathy, being able to listen to people, and resonate and understand what they're feeling, so that you can communicate effectively with them, and compassion, that idea of being able to sit with people while they're suffering, try to alleviate it as much as you can, or just sit with them through it if you can't reduce their suffering. And each of these domains is a way that we constructed and organized the various initiatives that we've developed over time. And Pep in Your Step is a program where physicians get counseling on how, at their level, they can become more efficient and spend less time in the tool. Rolling Resiliency is taking a cart of snacks around to folks in their workplace to say, thank you for what you're doing, have a snack, we love you, and let us know if there's anything that you want to talk about. We got an ear for a minute here. And these are additional resources if you need more time or want something more involved. And Caring for Our Caregivers is a peer support program with volunteers from the workforce who have been trained to listen to their peers when they're experiencing some kind of emotional distress that day at work of any type. I'm not gonna go through this list, but these are a variety of other resources organized around those three domains of resiliency. And we've measured burnout in the organization going back to 2017 with the Maslach Burnout Inventory, which is quite famous in the area. And then more recently with our own annual engagement survey which the entire workforce takes, Press Ganey divides resiliency into two areas. Activation, feeling kind of like turned on and excited and very engaged in your work. And decompression, which is being able to put your work aside when you go home and relax and try not to think about it and restore yourself. And you can see on the left, there were numbers from 2019 where we were doing kind of better than the national average on most of the scales. And then in 2021, we fell back a bit, not surprisingly, but in overall resiliency, but a bit more in decompression. And this was the results for the entirety of the workforce. And then for the physicians, this was the result which on the right-hand side in the bottom, you can see decompression is even more challenged. So we need to focus on decompression. P.S., that's my job this year. Good luck. So I just wanted to say something about this debriefing idea, because I wanted to share with you how helpful it was at our institution and how engaging it was to a large number of the folks who participated, although many were skeptical in the beginning and worried about possibly being traumatized. And some people didn't participate for that reason. And you know what, that's fine. You don't have, we're not gonna force you to do something for your wellbeing. You know, we just make something available if it's right for you, by all means, come in. So not knowing what the heck to do with the pandemic, I just decided to offer up some 40-minute, or I'm sorry, hour-long debrief sessions, which were labeled as supportive debrief sessions. So not debrief sessions where you just make everyone, have everything hang out and then say, you know, goodbye. But it was intentionally designed to be supportive. We did that between May of 2020, that's a typo there, and November of 21, and I got to about 40 different groups of people. And I had particular focus on people who were at the bedside in the most hairy situations, like in the emergency department and in the ICUs, the residency program. I also did some work with senior leadership, non-clinicians, various physician teams, nursing units, respiratory therapists, of course. And the program was offered out at large, and then was sort of sponsored by leaders in these various areas. And started, the session started with an introduction, welcoming, introducing myself, and starting out right away telling people how very thankful I am, and that we owe you a tremendous debt for what you've done that cannot be repaid. Just state it flat right out there, just get it out. And then I told them something about what happened with SARS, and we had good data from South Korea and Hong Kong, that there was about 25% PTSD in the frontline medical staff within the next, when they were surveyed, at a year and two years. And that, however, the risk of PTSD was mitigated by two things. One, having supportive leadership, which was interested in the well-being of the team members as they were going through the problem, and the opportunity to explore their emotional challenges of the pandemic by, in the presence of their peers, because their peers get what was going on. So, told people, you know, gave them the various instructions to, you know, the job is really just to share what has been most challenging. And thoughts also, because I wanted this to be a little bit uplifting and for people to share ideas that would be helpful, on what's helping people prevail and get through it all. And then thoughts on where future efforts or support should focus. And I instructed people to practice the skills of active listening, empathy, and compassion, and non-judgmental attitude. And I also shared additional resources that are available in our health system for emotional support. And I also, and many people avail themselves of this, and they still do, offered myself up as somebody who could help linkage them to services if they're not sure what to do for themselves or a family member, et cetera, in a fully confidential way. And then just to wrap up, I wanna talk about the topics that surfaced very consistently in these various sessions. Of course, at first, the whole PPE issues, the fear of becoming ill or dying, exposing family, friends, the rituals established at home to mitigate the risk, dealing with doing the work for team members who are out sick, isolation on multiple levels. And one certified registered nurse anesthetist quoted for me that COVID is the lonely disease. I don't know if that's original, but I love it. And I use that a lot. It is a lonely, isolating situation, right? They talked about the sheer volume of patients, the acuity of patients, the excess mortality, having an auxiliary morgue out in the parking lot, which was a refrigerated truck, the family being prevented at the bedside, leaving the nurses to do the virtual communication with the family, being thrust into the role of being the surrogate family member, the chaplain, the environmental team member, the dietary, and other roles, because the nurses were the only ones going into many of the rooms with the very sick patients, and the lack of effective evidence-based treatments, the moral distress involving those several listed above, and the evolving resuscitation protocols that were upsetting to people, as well as just the sheer inability to deliver the usual level of care because of the sheer volume. So, and then there were the issues of dealing with the outside world, most commonly the difficulty like sharing or really explaining to anybody who's not in the trenches with you what it's like being in the trenches, the ambivalence about the whole healthcare hero signage in the community, and the conflicting media messaging, and the politicization of COVID, and the denial and minimization of the seriousness of COVID by some members of the community. And the difficulty of being redeployed when you've been trained in one area to fill in another area. And then getting around to sort of the positive things, and it was interesting, like the arc of these meetings started with the most horrific stuff, and then went into sort of more positive stuff when people, I guess, felt like they needed to come full circle and say how they're getting through it all. They talked about how they were really appreciative overall of the leadership being supportive and concerned. They mentioned some opportunities for a better communication. They cited that barriers were lowered between the disciplines, and people were working together more collaboratively, and that was really cool for a lot of people, and it's something that they wanted to take with them into the future. And they found that the peer support, their peers in the moment, their familiar coworkers were the best people and the most helpful at sort of sharing what was going on rather than trying to identify a therapist or some unknown other entity out there. And they felt most safe, actually, and secure with their peers at work. People really liked the sessions. They did not find them traumatizing, and we had a net promoter score of 95, meaning that's likelihood of recommending. And just in conclusion, the pandemic is a unique, ongoing, shared trauma. Definitely, I endorse a chief wellness officer or a wellness officer-like leadership position in all large organizations. And I definitely endorse building, you know, thoughtfully, a resilience program. We were really able to build on what we had started in 2017 and 18 in our organization, and tap into that in 2020. That was helpful. Focusing on being nonjudgmental with other people and listening to understand them, learn, and adapt. Focus on connection. Several people mentioned that, but connection and the purpose, why we're doing this. Well, that's why people are in, that is what keeps people in healthcare is the why, the mission. And being inventive, allow yourself to do something that's a little different. Be gentle to people, be very grateful all the time, and be very deliberate and intentional about it. That's it, thank you. Thank you, Peter. Let me just see if there's anything more online. Put my glasses on. While I'm looking at this, any comments from the panel or questions? This is a little bit, can you hear me? Good, a little bit, this takes in some things that Dr. Libou mentioned, and also some that you mentioned. This is just an ethics issue for the future. Two of the stories you told, Rachel, involved refusals. I have in mind the 14-year-old who had needle phobia, and then the delivering mother who refused intubation. We, I think, and then some attention to people refusing vaccines. I think we need to think a little more carefully about how seriously we take refusals. It's become a sort of article of faith. Patient says, no, that's the end of the story. I think that that's short-sighted. I, you hate to recommend forceful, you know, forcible treatment, but on the other hand, to let a 14-year-old's fear of needle phobia and a 14-year-old's fear of needles result in death, right, there's something wrong with that picture. So, I'm just putting that on the agenda. The more complicated business is about. Can I say something about that, because I have a personal experience about that. When I was an intern, that was very informative, and it was, I was an intern in the ICU, and there was a man very short of breath, and he was refusing intubation, and he was refusing intubation and refusing intubation, and I don't know that we exactly jammed it down his throat, but he was intubated, and he lived, and a month later, he came back with such gratitude that he had been forced to actually go ahead with a treatment that he was resisting with all of his power. So, I think there's situations where clinicians, wills, almost have a breathe a sigh of relief that the person's refusing, because then they don't have to deal with it. That's a very skeptical, but there is that motive, too, and I think, really, it is grist for the mill when somebody refuses, and it should just, it should prompt a conversation, because maybe something's being missed. Oftentimes, fear, right? People are just afraid, and they don't wanna lose control, so you need to have, allow them to have some control, and you need to address what they're afraid about, yeah. And, of course, the vaccine business is, in COVID, is, of course, central. Hello, everybody, and thank you so much for this extremely engaging and important conversation. These are some of the harder conversations that we have to have and will continue to have. My name is Rosandra Day Walker. I'm occupational medicine trained, and also a total worker health trainee. I have one comment and one question. The first one was to the question or comment that was posed about asking people to take on additional responsibilities as champions for wellness or for resiliency in the midst of being already overwhelmed and burned out, and something that I have found to be helpful, and I think that more leaders just have to make that paradigm shift, is to, we either have to speak to the loss aversion that most people respond to, and what I mean by that is, are you willing to see your institution or your people continue to suffer and crumble or lose five more employees, or will you give two hours of protected time to this enthusiastic person who wants to be a champion of wellness for you, but doesn't have enough time or support? Are you willing to put up the resources to support that person to be that and help your culture survive and thrive? And I say that because my husband actually did that for his institution, working in a community health center, he's actually back there hiding, where they are traditionally overwhelmed and under-resourced and everybody was burned out before COVID, but somehow they found a way to say, okay, we have to step back from this overemphasis on productivity and the widget factory to save ourselves for a few minutes. My other question is, about the chief wellness officer-like position. So I've wanted to be a chief wellness officer since before COVID, since I was a little second year ENT resident before I saw the light and came to occupational medicine. And at that time, it wasn't very popular and probably got a little derision actually when I would bring that kind of stuff up. And I know that now in this current, this new world that we're in, from COVID and social justice and everything that we've moved through, it seems to be a lot more popular. And it's definitely popular in our circle here in occupational and environmental medicine. But I do remember a lot of kind of cynicism towards the idea of appointing yet another administrator, and is that really the answer? So I believe in it, but how do you speak to people about that? So I think times have changed and this is the moment to capitalize on it. And I think you will become a chief wellness officer. A little small point, I positioned my, I advocated for the role myself and I decided not to go for a chief wellness officer and add yet another layer of very expensive C-suite personnel and rather ask for a halftime job because I didn't want to leave up my clinical work to focus on this area. And I renamed it a resiliency advocate because I like that. It's more like from the people for the people, right? Like union, yes, let's do this. Let's get it done. So it's an advocacy kind of position. So that's one potential strategy, but this is the time to do it. And if you need a little extra firepower, that is one of the top five things that the AMA said is asking every healthcare system to action on, on their list. Hire a chief wellness officer or a similar position. So you will be that person if you want to do it. But you have to figure out how to not leave behind your occupational medicine stuff because you're needed there too. If you could do both, I would pause. So we are formally out of time. So I know we have, maybe come up, but I want to thank the panel members and thank you, the audience. I think this is a wonderful opportunity to talk about tough stuff.

healthcare workers

COVID-19 pandemic

physical safety

mental safety

workforce impact

ethical considerations

triage situations

moral distress

supporting healthcare workers

preparedness

resource allocation

moral resilience

ethical decision-making