Hello, and welcome to today's webinar, System Perspectives on Healthcare, Worker Burnout and Well-Being During the COVID-19 Pandemic. My name is Danielle Feinberg, and I am with the American College of Occupational and Environmental Medicine. There are two features available to communicate with the panelists and other attendees. You may post general messages in the chat feature. Messages can be shared with either the panelists or all participants. Use the drop down box to select who you want to share your message with. Go ahead and give it a try. Introduce yourselves to all of the panelists and attendees. Let us know your role and where you're from. Questions, on the other hand, should be submitted to the Q&A box. We will be monitoring this box for questions. Please be sure to post your questions here, not in the chat box, and we will allow for Q&A at the end of the presentation. If you're not familiar with ACOM, we are a membership organization that promotes the health and safety of workers, workplaces, and environments through education, research, development of public policy, and advancing the field of occupational health. Before we get started, just a reminder, today's session will be recorded. An email will be sent to all attendees with a link to the archive recording, as well as those who are unable to attend. We are delighted to have Dr. Mara Bookbinder and Dr. Lucas Mazur with us today. Dr. Bookbinder is a professor of social medicine and an adjunct professor of anthropology at UNC Chapel Hill, as well as a core faculty in the UNC Center for Bioethics. She is a medical anthropologist with broad interests in cultures of health, illness, and medicine in the United States. Her recent work focuses on how patients, families, and health care providers navigate social and ethical challenges resulting from changes in medical technology, law, and health policy. Dr. Bookbinder is currently the principal investor of the study to examine physicians' pandemic stress, also known as STEPS. With the support from the Greenwell Foundation and the National Institute for Occupational Safety and Health, STEPS will integrate qualitative with conceptual analysis to investigate moral stress experienced by physicians working on the front lines of COVID-19 care. Dr. Lucas Mazur earned his BS, MS, and PhD in industrial and management engineering from Montana State University. He's an associate professor and a director of health care engineering department at the Radiation Oncology Department of UNC School of Medicine. He holds a joint appointment with the School of Information and Library Science, where he teaches classes and advises students on their projects and research. His research interests include engineering management as it pertains to continuous quality and patient safety efforts in health care and human factor engineering, with a focus on workload and individual performance during human-machine interactions. His most recent interests include application of data science and tools, natural language processing to augment the medical decision-making and quality assurance process. Dr. Mazur was awarded the prestigious Alumni Outstanding Extension Service Award for his outreach work in the health care industry, highlighting his passion for patient safety and operational improvements. He's published over 50 peer-reviewed papers, over 100 conference proceeding abstracts, five book chapters, and co-authored one book. We are glad to have you here with us today, and we are looking forward to our webinar. I'll now turn it over to Dr. Mazur. All right, thank you. You can hear me okay? And just want to make sure you will be able to see my slides. I'm going to share my screen right now. Let me do that. So I'm sharing my screen, and I just want to make sure that everybody maybe get a confirmation that my slides are all ready to go. Yes, okay. Thank you so much. Thank you for the wonderful introduction. I appreciate that very much. And I also want to thank for this opportunity to speak today and share the learnings on some of the projects that we are conducting here in our state. Just to set the stage, I am an industrial engineer, and a lot of my experiences are coming from that angle. So in my presentation, I do want to emphasize that a lot of the angle of the work that we are taking on, perhaps takes a little bit on that approach of thinking on the system as an engineer. And I think that will kind of come through my presentations as I'm presenting. The work and the project that I will be speaking about today kind of comes from our center that has been recently created here at UNC under the great effort of Dr. Linnan. And as you can see here at the bottom of the screen, in the center, we received an award, a project that allowed us to work with the EDs, our emergency department departments, across our entities at the UNC system. And I'm collaborating and really presenting this work on the behalf, not only of myself, but the great collaborators of Dr. Meltzer Brody. She's the chair of the psychiatry department here at UNC, and also Marian Bernholt. And she's the dean of nursing at the school, the UVA in Virginia. So again, there's a lot of great effort happening and a lot of learnings as we are kind of conducting this type of a work here at UNC. The project that I will be presenting and talking is really trying to better understand how, over time, if we measure kind of these endpoints of our study, when we look at nurses and providers, our MDs, burnout, depression, moral distress, you know, well-being. You know, can we really take good measurements over time and better understand exactly what's happening in a field and really kind of dive deeper into these topics. And then aim two will be to test and really understand if we're going to make any improvements in the system at different levels. If it's individual improvements, if it's going to be unit-based, organizational policy that's going to change. Can we truly understand how much effect do we have making these improvements on these endpoints of the studies? We are currently conducting, we are in aim one, and I will share some of those initial results and try to maybe kind of, you know, make us think about what's happening and what we're seeing in the data, you know, as we are really starting to get some of the results. So before I, you know, before I kind of get into the results, you know, thinking about the system, and again, thinking from an engineering standpoint, we look at the EDs, and we really need to recognize that there's a lot of interdependent roles that people were taking on during the pandemic. Right? There's a lot of multidisciplinary team members that need to collaborate, not only within the ED, but also to be able to coordinate with the inpatient units, right, and then x-ray and others, other departments. So there's a lot going on, and we know that the shortages of staff that were present during the pandemic made it even that much harder for people to coordinate. So a lot of coordination. The expectation is to provide high reliability, right, to make everything perfect, putting a lot of stress on folks. So we needed to have a very specific model that will help us kind of get there to better understand it. So we used the National Academy of Medicine system model to study physician burnout. And as you can see, what this model gave us is really defined 21 work system factors to get us started. So it gave us a good foundation to how can we start understanding and measuring the factors that affect these workers in this, in this, in the ED. And of course, we got to take it through the individual factor, the people that live in that, in this, in the system, and how does this kind of get to our endpoints, right? We were extending the burnout into the depression and moral distress and moral injury and others to better really understand how this works. So that was our starting point to have a framework, to have a base that allows us to kind of move forward. So to get our data, we did it in phases. We approached the ED and set up kind of this expectation to collect their individual perspective on these 21 work system factors that I'm going to be talking about using a survey. Not the most popular way, knowing that people were extremely tired. There was a lot of other surveys, a lot going on. So we knew that we are starting somewhere and asking a favor from these EDs to be able to answer these questions. But that's where we needed to start to get a better sense. The next step was to take this data and really go back and present it to the people that actually took it. We were, we kind of knew from the beginning that if we give people an opportunity to look at the results from the survey and really talk through this and ask if they need to actually reprioritize, rethink it, and tell us more of a contextual story of what does this individual responses really mean. And finally, what we have done, it really is the deep dive effort, we went on site. So we went during the day shifts and the night shifts, in the mornings, in the nights. And we wanted to spend as much time as we can in the field, following the folks and really understanding what are those stresses, what are those factors that truly contribute to their stress, the burnout and other elements. So this was, you know, kind of that spending time with the individuals and learning as much as we can. Finally, getting and organizing all this data in a sense that it's presentable, so that we can ask the folks from the frontline to tell us, so what is, you know, is this valid? Is the data that we've collected, do you agree that we got it right? Does it make sense? And finally, asking them to prioritize, to find the improvements they need right now to move forward, to make the system better. And of course, at the end, you know, as you can imagine, you know, this needs to be read, the recommendation is to be organized, put for the leadership teams and organized in the short term, long term, and so on. So that's the procedure that we are following. So let me kind of, you know, just jump and show you some of the results that we are capturing. So we have the urban hospital that we are working with. And there was about, you know, 81 people out of about 50% of folks working in that unit gave us responses. And about 121 people gave us responses from the rural entities, you know, three different entities. And that represented about 30% of the responses in that case. And I want to show you that, as you could imagine, individually, when you take a survey, and you talk about these work system factors, in a shortage of staff that was experienced, it wasn't a surprise to see that the number one factor contributing to these, you know, to these endpoints of interest for us, like burnout, would be inadequate staffing. Yes, we were in a shortage. And that's what came through in a survey, right? We also see a lot of things about workflows were not optimal. We had some interruptions, time pressure, there was a lot of workload on people to be able to cover the shifts. So those are the top five that I'm presenting here on the slide. The one difference between the urban hospital and what we don't see in the rural was this organizational culture, right? So in the rural hospitals, we did not see that culture was coming strongly as a contributing factor versus in the medical center here, where there's a lot going on, the culture kind of came stronger. So we took this data, this on what you see in the slide, and we went to the focus groups to ask, okay, this is what you believed individually, when you were taking the survey. So we spent quite a bit of time with folks, we conducted 19 focus groups, about 45 to 60 minutes at length. As you can see, there were seven of them that we formed in the urban hospital. And from rural, we were able to get people to participate in 12. Again, very, very challenging, as you can imagine, to schedule. People were extremely busy to bring them to a dedicated focus group, and we've learned. And what I want to tell you is that things shifted. They started to shift tremendously. Those individual responses from surveys, as it's still valid, but the prioritization of what really was important in terms of just looking at the survey scores from a Likert scale of one to five, so to speak, right, strongly agree to disagree, they shifted. People start having conversations, and we asked them, would you like to reprioritize the list? What's really the number one? And things start moving a lot. And that was a good indication for us before going on site. So then the next step was to even learn more, would be to go and conduct what we call contextual inquiries. It's a form of shadowing, but the point is, if you spend four to eight hours with an individual, can you build a partnership during that time? So they can truly open up and tell you about the details, about what really is happening in those workflows, in the organization, at the individual level. So building a partnership and trust during this visit was our main approach as researchers. And please know, just personally, I spent time working through nights in the ED, just knowing that there will be a little bit more time to maybe build the relationship, because during day shifts, it was incredibly, to see the pace of work was so, you know, so outrageous, almost, you know, I would say, that we couldn't even exchange a word in four to six hours. The provider was so busy, there was not even a way for us to interact at any point. So those were those contextual inquiries. We conducted 21 of those as a research team across these entities. And what I want to show you is, imagine all this data being now everything we've captured, all of it. We've created 430 individual notes, cards. Think about them as individual cards. And we got, so from focus groups, from being there in the context, knowing the survey results. We sat down in the room as the researchers, and we've taken these cards, divided kind of randomly between all of us, and we start building this affinity diagram from bottom up. Literally, we just say, we just not assume anything. Let's start making sense what they told us. Let's build this up. So the model, as you're building it on a really large wall in a room, and you, you know, you bring in these cards, and you're thinking about how do they belong to each other. These are the constructs which you start seeing of the affinity. This is what came out. And I'm going to tell you that the biggest thing, the most cards, you know, probably in about 30% of the cards that were there, they belong to moral distress. They belong, and they manifested the almost like a moral injury that people are already, are under the pressure. What has happened is not just the distress, it's where they were. So there was a very much context about what moral distress is for us. And I'm going to show you a little bit about this on the next slide. And I want to show you that the other things that were coming through were the culture, the policy and broken processes, like how the patients and families were affecting their job, right? There's a lot of workplace violence that is happening in this, that's affecting all these things. And look at that, as I'm kind of presenting this slide. Yes, we got, we learned more about staffing issues. But this is not, the staffing, as they are important, they need to change, of course. They were not something that were manifesting in those voices of these individuals. You know, the learning is tremendous. So I'm going to show some, just to give you a sense, 430 different notes. Each of these bullets would represent some sort of a card. And I tried to kind of help you guys kind of see it. But I'm going to read one or a few of those. So under moral distress, as you can see, self-preservation, existential crisis, right? You know, moral distress due to poor teamwork. Those things are starting to really come through and make you, help you understand what these people are going through. So here's a quote, you know, I'm going to read the pink one just so we can maybe see it. But one of the examples. My husband wants to, wants to understand. He tries, but he just doesn't. He will never get it unless he works my shift. But your co-workers get it. It's that sense of comradery that you can't get from anybody else other than ED. Not even other nurses get it. Unless you work down here every day, you don't get, you don't get it. It's very different from anywhere else in the hospital. There's other crap we have to deal with between abusive patients, abusive visitors, and then the traumas and seeing stuff, not the same thing as being in ICU where they are all stitched up and packaged up or ventilated and intubated. You know, we deal, we deal with it from the beginning. It's not the same. Now I read this because I want to kind of bring the reality to, to what, what these issues are, what people feel and how, how, how careful we got to be thinking about the system interventions that we're going to implement to help people after the pandemic. And still, it's still a lot happening to be able to address these issues and prepare our workforce for the future. And really tell them that this is a great place to work. So I'm just looking at the time. I'm not going to read all this, but I hope that the one that I read, you know, allows you to kind of really see the picture, because just the amount of work and understanding that goes into now really connect with the individuals and better prepare yourself for the conversation about the intervention and the system change, you know, lies in these details, right? As the researchers, as the leadership teams, administrators, if we don't fully engage and understand, it's going to be very hard for us to implement a change that is going to be sustainable. You know, again, and just, just, just kind of looking through this, you know, there's just, there's just lots of, lots of, lots to learn. So, you know, I'm going to wrap up on this slide. And I want to, want to say that initially, you know, we are already preparing to come back and, and validate all these quotes, validate all those feelings with, with our people that gave us. That's our next step in this, in this research effort. And the next, next question will be, how can we organize the system interventions that will allow us to kind of put, what can we do in the short term, right, with a high impact, but maybe less effort versus what are those long-term investments that the organization as a whole needs to take on and change certain policies to be able to affect this long term, right? This is not an easy thing to fix. There's a lot going on, but it deserves, it deserves kind of that, that contextual dive, deep dive to better understand. So, you know, that's my message of today. What I wanted to share with you is, is really, you know, making sure that it takes this research, it takes this effort, but, but going to the depth of understanding, I think is the only way for us to truly come up with the ideas that can, you know, help, help these things. So thank you so much for your, for your attention. I'm happy to take any questions now, or I think we might be transitioning to, to Mara for the next presentation. Thank you. Thank you, Lucas. That was great. I'm just going to go ahead and share my slides as well. Okay. so thanks so much for the invitation to be here and I think that my presentation is going to follow on Lucas's quite nicely and provide a little bit of qualitative context to some of the really interesting points that he made. So I'm going to be presenting findings today from the study to examine physicians pandemic stress, which is a project that I direct. Steps is funded by the Greenwald Foundation, the National Institute for Occupational Safety and Health and the Department of Social Medicine at UNC Chapel Hill. I want to acknowledge the rest of my team, which includes my co-investigators at UNC Chapel Hill, Tanya Jenkins and John Staley and Nancy Berlinger at the Hastings Center, as well as consultants in the cities that we worked in and our research assistants. And Steps is composed of two interrelated projects, which are funded by the Greenwald Foundation and the National Institute of Occupational Safety and Health, respectively. Each of these is based on qualitative interviews with frontline physicians in two U.S. cities and each includes descriptive as well as policy aims oriented toward addressing occupational stressors and improving physicians' professional well-being. So why did we do this study? Even before the COVID-19 pandemic, U.S. physicians were at high risk for occupational stress and burnout and interventions targeting individual resilience have consistently fallen short. Of course, COVID has made things worse. A survey by the National Institute for Healthcare Management found that 76% of U.S. healthcare workers reported burnout in September of 2020, which was up from 30 to 54% in 2019. While physicians globally have reported increased levels of depression, anxiety, and PTSD. So it's really been clear that better strategies for responding to stress and burnout are urgently needed. And focusing on individual level interventions like yoga and mindfulness really, I think, risks blaming the victim by assigning responsibility to physicians to heal themselves of an unhealthy work environment. So increasingly, as Lucas just spoke about, researchers are calling for systems-based approaches that look for upstream sources of occupational stress and burnout. But in order to develop such interventions, we need to have a better understanding of the structural sources of these problems. So overall, STEPS has a comparative design aimed at assessing physicians caring for hospitalized COVID-19 patients in four American cities. And they are Los Angeles, Miami, New York City, and New Orleans. And the physicians come from a range of specialties and hospital types. Our goal was to address how differences in state and local public health responses mediate the ways that individual physicians have experienced this crisis. We conducted the semi-structured qualitative interviews over Zoom. And we asked questions about personal background, onset of the crisis, institutional practices and policies, working during the pandemic, and personal well-being during the pandemic. The Greenwell study began first. And we decided to focus on New York City initially because it was the epicenter of the US outbreak beginning in March 2020. And New Orleans provided an apt comparison because it peaked at relatively the same time. And then for the NIOSH study, we decided to look at LA and Miami because both of these cities peaked relatively later on. And we wanted to look at them as well because they had very different political climates. And we wanted to understand how that was affecting physicians' experiences. Our final sample from across the four cities included 145 physicians. Most of these were under age 50, just over half were women, and 70% were white with 90% being non-Hispanic. Their mean number of years of experience was 10, and they worked at a total of 44 distinct hospital types with diverse funding structures, sizes, and patient populations across the four cities. A third of them worked in safety net hospitals. Our conceptual model is adapted from this model proposed by the National Academies of Medicine. Lucas presented this model earlier. And essentially, it depicts frontline care delivery as shaped by both organizational and external environmental factors, which interact to shape clinician outcomes such as burnout and professional well-being, in addition to patient-level outcomes. And we modified the NAM model to include attention to the role of professional-level factors, such as professional norms. And so our goal was really to assess how differences in each of these structural layers mediate the stress and well-being of individual physicians. We asked all of the participants in the study what was most challenging about working during the pandemic. And participants shared a range of responses across the levels of our conceptual model. They provided a total of 367 responses to this question, so they offered more than one response on average. At the individual level, concerns about viral exposure at work, transmission, and the safety of one's family were mentioned most frequently. At the institutional level, workload and volumes of patient deaths was mentioned most frequently. At the professional level, medical uncertainty and the suboptimal care came up most frequently. And finally, at the societal level, we heard most about mistrust toward physicians and COVID skepticism. So what I want to do next is delve a little bit more deeply into each of these levels and share some participant comments with you. Not surprisingly, we saw some individual-level variation in how physicians weathered the challenges of COVID-19. So age and years of experience seemed to matter for how they responded, with many younger physicians noting that they simply hadn't had as much clinical experience to draw on prior to the pandemic. Family situation also mattered to individual stress as well, because participants had varying levels of concern about viral transmission, depending on who lived with them in the household. And we also saw that parents of young children and pregnant women faced particular challenges. So this next quote from a hospitalist in New Orleans is illustrative. And she said, I don't think I realized at the time, but I was having panic attacks. That became an issue for me. It was from, I guess, PTSD or whatever was happening. Just the volume of work being too much or more than I was used to and feeling undersupported or unsupported. And part of that was I was so quick out of residency. I was so green to being on my own anyway, and then sort of being thrust into this situation where we didn't have any data and didn't even know how to take care of these people. And I already was still learning how to do this on my own. That was a challenging part for me too. But one of the premises of our research is that it's not just the individual factors that contribute to physician stress and burnout, but also the ways in which structural context shapes these individual factors. And in this case, there were several things that are worth pointing to that were really crucial to the experience of this physician. So not only was she a new attending, but she was working night shifts at a small community hospital where she was the only physician on call overnight. And in addition to covering the medical wards, she had to cover the ICU without any critical care backup. So she was working alone, covering patients that were less familiar to her, and in a different type of hospital, she would have had much more support. And it's also worth noting she was assigned to this nocturnist role precisely because she was the newest hire, and this was a very undesirable position. At the institutional level, participants reported striking disparities in resource constraints between different hospital types. With public hospitals, and especially those in New York City, facing much more dire constraints in general. And those differences matter to patient care, which in turn matter to physician stress levels. So this quote from a critical care pulmonologist in New York speaks to this theme. I would say there was a dichotomy between private institutions and public institutions. For example, my institution worked with a lot of private institutions to give them ventilators that they weren't using and all of that. They didn't do the same thing for the public hospital. And I think it created that tale of two cities that often is the reference to the way that this crisis was managed, and other crises as well, that if you're poor, you live in certain neighborhood and all of that, you're going to receive poor care. And then this hospitalist in New Orleans expressed similar views. She said, you know, the grapevine word was that there's another hospital organization in town that had a lot more money than we did. And they scooped up a lot of the resources pretty quickly. And so then it took us longer to find the resources that we needed in terms of the equipment. So I mean, issues like that, where if you've got money and you're first in line, things will be probably going better for your organization than not. We definitely felt some of that, but it also wasn't new. The professional level of our conceptual model refers to the professional norms, practices, and cultures that implicitly and implicitly shape clinician well-being. And a major stressor at this level entailed the inadequacies and uncertainties in caring for patients with COVID-19, particularly early on in the pandemic. Many participants described feeling helpless, which contradicted their medical training and their sense of professional self-efficacy. Uncertain medical knowledge created questions about whether one had done everything clinically leading to self-doubt. So this is an example from a hospitalist in New York City who said, I couldn't look a patient in their eye or talk to their family and give them any sense of whether they were going to do well or not. And I think that there's a real struggle because I wanted to provide that reassurance. And because I couldn't, I felt like I was not being a good doctor. If I provided inaccurate sort of reassurance or concern or whatever, I think it was magnified because of the sheer amount of fear I saw in my patients' faces and the voices or faces of their families when we called or FaceTimed them. And there was this definite erosion in my sense that I knew what I was doing. Participants in both New Orleans and New York City noted that they had access to more resources in virtue of being hit first and hard. Nevertheless, many of them still felt abandoned by the federal government and harmed by the mixed public health messaging. So this emergency medicine physician in New York said, it felt just over and over again as if we were just hung out to dry. I guess we all had the sense at the beginning, like, we're in America. This is a great country. We have resources. Even if everything isn't perfect in the healthcare system, the state will come through. FEMA will be there. There will be some sort of centralized response to this thing and we'll get help. And it just didn't happen. So overall, participants expressed disillusionment with the failure of this great nation to provide for them. This sense of abandonment was expressed most strongly from physicians in New York City who worked in public hospitals. Many participants also brought up the politicization of COVID and the large scale mistrust of physicians as a stressor, although this came up less frequently in New York City and more frequently as the pandemic went on. So this quote is from a critical care pulmonologist in LA who said, this is not what I signed up for. I get disrespected. They're difficult. They're obstinate. We get verbally harassed. It's not fulfilling. It's discouraging. It's pretty hard to keep on going when you have to go in and face these kinds of working conditions. And it was ultimately incredibly demoralizing for physicians to work tirelessly fighting this virus that many of their patients did not believe was real. And one person that we interviewed even ended up moving as a result of this out of New Orleans and to a more liberal area of the country. One of the primary objectives of this study was to understand how the various stressors that we identified at the institutional, the professional, and the societal level affected physicians' professional well-being at the individual level. And we found that these stressors affected participants' well-being, leading to burnout among some. So this next excerpt that I'll share with you is from an emergency medicine physician in LA, and it highlights the impact of societal level stressors like COVID politics and an inadequate government response on individual well-being. So the interviewer asks, has the government response served as a stressor at all for you throughout the pandemic? And the participant says, certainly at the beginning. It was this sort of ivory tower disregard for the pandemic that was contrasting with our day-to-day lived experience, was very hard to reconcile, and very hard to hate, to not hate, and feel very angry about. I think I feel very fortunate to live in Los Angeles, where I feel that in a local level, that if anything, we've erred on the side of being overly strict. I would say from a federal level, that was really jarring. And I think that really contributed to a lot of mental health issues and troubles that a lot of us were experiencing. It was the rhetoric from the government that this didn't exist, and that this was a hoax, and this was whatever. When we were living in fear for our lives and just wanting to invite a lot of those deniers to spend a day in our lives, that was very hard. We have many more examples of these relationships across levels of our conceptual model, and I'll just share a few because of time constraints. Several New York City participants acknowledged inequalities between neighborhoods, which is a societal level stressor, shaped hospitals' abilities to respond to surge conditions at the institutional level. And these effects were especially pronounced in the hardest hit, that is, most socioeconomically disadvantaged areas of New York City. Hospital visitation policies, which was an institutional level stressor, likewise unsettled norms of patient care, a professional level stressor that enlists family support. And finally, communicating with families who distrusted science and thought COVID-19 was a hoax, disrupted physician norms against resenting patients, showing here the interplay of the societal level with the professional level. One of the products of the Greenwald Foundation STEP study was a set of recommendations for chief wellness officers, which is an executive level position responsible for championing the well-being of hospital-based clinicians. And we decided to target our recommendations to chief wellness officers because we thought that they would be best positioned to respond to our study findings and implement systems change for addressing clinician stress and burnout. And so we developed recommendations in six domains, and they include, so in terms of intensified feelings of powerlessness, our recommendations were to commit to learning from physicians about institutional factors that impede good care, through regularly scheduled paid feedback sessions that include leadership, and to promote quality improvement research on workplace conditions that impede good care. For institutional policies, our recommendations were to solicit frontline clinicians' input throughout the development and implementation of new patient care policies and processes, and to request feedback from unit leaders regarding the impacts of policy changes. So as with regards to inequities that were pervasive during COVID, our recommendations were to recognize feelings of complicity and injustice to patients as corrosive to clinician well-being, and to collaborate with diversity, equity, and inclusion administrators to incorporate DEI priorities into wellness programming. In terms of misinformation and mistrust, our recommendations were to acknowledge mistrust as a societal phenomenon that will continue to affect clinical encounters, and to contribute to wider institutional efforts to build trust with patient populations, and to help frontline clinicians respond to misinformation and mistrust. We also recommended that institutions recognize improvised practices or workarounds developed to manage new or intensified workflow challenges under pandemic and everyday conditions. So we saw a lot of creativity and improvisation with new ideas during the pandemic, and we wanted to try to harness these innovations for positive change. So we also recommended that health systems study these practices and their outcomes as potential sources of practice innovation. And finally, we recommend that chief wellness officers create opportunities for clinicians to explore causes of work-related moral stress, and to share promising practices with and between units, and really build on the strengths of community and of the camaraderie that we saw among clinicians during this time. And secondly, to create leadership training and mentoring opportunities for unit leaders to cultivate unit-level cultures of inclusion, well-being, and advocacy for improvements. And we are currently going through a similar process of developing recommendations for our NIOSH study that we'll be going through over the next few months. All of these recommendations and a summary report are posted on our project website, and I will share a link to that at the end. So just to conclude, what can we conclude from this brief snapshot of the experience of 145 frontline physicians working during COVID? Individual-level factors like resilience cannot account for how physicians cope with pandemic-related stress. Understanding stress and burnout really demands a systems perspective. Some participants in our study would have been able to navigate the onslaught of stressors more effectively if they had only had a more supportive institutional environment, or if professional cultures were not undermining their sense of professional efficacy and integrity, or if they weren't confronted on a daily basis with patients who challenged the reality of COVID. Our interview findings thus reflect interactions between health systems, work environments, professional norms, and individual well-being. And this suggests that medical institutions may fail physicians doubly, first by fostering practices that compound individual experiences of stress and burnout, and second by neglecting to provide effective programs to promote worker well-being. And here is a link to our project website and summary report, and I can also put that link in the chat as well. I will stop my slides so that we can move to Q&A, and I think both Lucas and I are happy to take questions at this point. One second, getting the slides back up. While I am getting these presentations to go, there we go, let's try this one more time. There we go. Excellent. Thank you so much. I do apologize about that sometimes technology and I do not agree. We do have quite a few questions that came in. Our first question is, can you please comment on the results on individual factors, such as gender, race and ethnicity. I'm not both of us. It's just a general question it doesn't look like it's directed to either one. Correct. I can, I can start and then Lucas you can jump in if you'd like. So, let's see, I mean we, we definitely found that physicians that were members of historically marginalized racial groups did seem to report increased levels of stress during the pandemic. And of course, this is coming from our qualitative studies so these impressions are somewhat subjective, particularly because we had fewer. We had less representation of those groups in our study to begin with, but I do think that some of them had this sense that they were, you know, for one thing many of them had family members that were adversely affected by the pandemic and they were kind of fighting this pandemic on the front lines at work every day and then they were also kind of seeing the racial reckoning unfolding on the news and sort of in the world around them during this time as well so I think it was a very difficult time, not only for black and African American physicians but also for Asian American physicians we heard a lot from physicians in in LA, who actually felt very safe in the hospital and faced a lot of discrimination outside the hospital. During this time due to kind of backlash against China, regarding COVID-19. Age and gender is interesting I mean I think in our study we found that younger physicians in general tended to. Many of them like they were having a harder time many of them had small children at home and that was a big stressor, there were also sort of the issues of being relatively newer in their clinical expertise that made them kind of feel less confident. They seemed to be the physicians that were sort of in their 40s and 50s that that in our study seemed to weather the challenges of the pandemic best. Lucas do you do you want to add to that. Those are great points and in our in the study I presented as a sample size is a little bit too small to be able to really have a representative voice, you know by by you know the gender, of course, most of the. It was it was female that we were working on we still doing a lot of data analysis and I hope we're going to learn some more details, you know, in that sense. But I do agree with with the point, you know, looking at the five years of my practical work also utilizing similar approaches across the system. And doing this work that you know I like what what you mentioning about this, this difference in their resilience of that people may be picked up over many years of practice right that they've been building and going and taking workshops and kind of building their toolbox of different tools that they can use during these challenging times right. And I think that would be a very interesting way of analyzing the data you know then then going into you know race and ethnicity and everything else and really trying to realize you know how much experience and toolbox. Do you have so you can add the individual level deal with these. And then as I will step in you know the more the interesting facts people that are really well connected you know some of the physicians that practice more inequality improvement and physicians that are connected to the well being program and better understand the connections throughout the organization, not just for their practice, they tend to also at least there's a pattern of the recognition that they, they tend to kind of again know how to connect, they know how to maybe respond better and they don't just stay alone in a problem that is just growing on top of them right so I just want to bring maybe that interesting point, I don't have a data to prove it. But it's just kind of a hinge that the folks that you know have those connections and the bigger toolbox, maybe are dealing a little bit easier with that with the issues. Excellent. Thank you both. Dr Mazer this question is for you. The impact versus effort chart slide is very interesting. Could you please comment more about your insights of the results shown for this well designed chart. Thank you. Thank you for this question is an excellent one and I'm again I'm going to draw across my experiences a little bit more to answer this, as I think this is important to share. So you know I will kind of represent kind of a low effort and high impact and let's talk about chairs of the departments, right leaders in the departments that dealing with this issue and during the pandemic. Those are the folks potential as medical directors taking the calls from the nurses that we, you know, and all the providers that we're talking about saying what I'm supposed to do. You know I'm here I was on the shift, and I'm making all these clinical decisions that I'm not comfortable with I'm exhausted right but there's some way of calling someone right of course you talk to your colleagues, but the, the leaders in the departments that we are seeing that we're picking up these phone calls and they were serving as you know the colleagues that yes I'll help you I'll help you make a decision what to do next. You know under this uncertainty. These folks require certain things and I give you kind of examples of what manifested which is, you know, it's just fascinating to me, and I'm going to pick on plastic surgery because it was fresh in my mind as an example, and a plastic surgery chair who's also been dealing with a certain this of this issues tells to us, you know, what you can help me with on the low impact to make me believe that we heading somewhere with the improvement work. I don't want to go to ground rounds anymore. Be checked for attendance and have my and have my, you know, bet you know my kind of extra pay attached to it, and we never talk about plastic surgery in the ground rounds we always cover you know heart and brain and So, I'm giving an example that as you speak with different people that the low effort high impact things could be extremely just a decision making process of the leader saying recognizing that we can help immediately. Like, we can help next week to remove stress and factors for people to to just to deal with how we work. Right. So I just, I want to kind of bring those up and there's many examples of what we can do tomorrow. All right, so, so please know that the data that I was sharing and I was really emphasizing kind of why we got to go to the depth of understanding to be able to then understand what the moral distress is, what the burnout is and provide support immediately tomorrow versus the programmatic and I really like what Dr. Bookbinder was presenting know what can we do programmatically within organization. Yes, it's going to be high effort and high reward right so the impact is going to be larger. But we also need to rely that in these are in our organizations we have structures, we have some sort of a well being program. We have a quality improvement program there is a risk department. There are a lot of people that want to do this right if we can integrate our systems together to to offer a way of bringing issues up escalating them on a daily basis, getting feedback, right, not just there's improvement tomorrow but getting proper feedback from our leaders that they are hearing us that there is an issue, and they're start working with us towards the resolution in a very programmatic and systematic way, so we can achieve the high reliability and all the measures that we want. Those are, that's the work that needs to be also conducted but we're a lot of times we're doing everything in silos, we not collaborating so you know I'm. You know that chart kind of allows us to better understand, you know what needs to be done at the, you know, the programmatic levels versus what do you need to do tomorrow so. So thank you for that question. Thank you. I believe that this question is for Dr book binder. It seems that mistrust rejection of science and medical advance was a major problem dealing with abuse and lack of respect. Did this mistrust occur between providers are just from patients. And that's a great question. I think it really was limited to between patient between providers and patients and sometimes family members as well. I will say that I'm currently, I've just started a new research study looking at obstetrician gynecologists in states with abortion bans kind of in the aftermath of jobs, and we're seeing a lot more in that study trust propping up as an important theme among among providers and and sort of missed not knowing who you can trust amongst So, you know that that's a very very new study the data is just coming in but I'm really interested in thinking more about trust in that context. There's a follow up to that question. Thank you so much. What criterions criteria made you and your team select these places and cities for your study. So, initially we knew we wanted to look at New York, just because it's where all of the action was at the beginning and we're writing these grant proposals. We had actually planned to look at Seattle in comparison with New York in the very beginning because it seemed like Seattle like Seattle was another big epicenter. As the pandemic was unfolding in the US and we ran into some recruitment challenges in Seattle, be in part because there were some other qualitative studies that were happening around the same time and we felt like maybe saturation had been reached in that small city and we decided to pivot and look at New Orleans because New Orleans was hit really hard, really early on and it ended up being a really happy sort of accident because we were really interested to look at a city with different racial demographics Seattle is a very white city. New Orleans, also shared with New York. One thing that that was really interesting and did come up is that both of those cities have been through kind of major disaster events, so Hurricane Katrina came up quite a bit when we were interviewing physicians in New Orleans and they often said this is nothing compared to Katrina, whereas in New York, things like 911 sometimes came up, H1N1 a little bit as well. So we decided to kind of pick cities that would prove interesting comparisons for these reasons. When we got additional funding to expand the study to two more cities, we thought that we would look at cities that peaked a little bit later on. Looking at summer 2020 and then into that winter surge of 2020 and that's when we settled upon Miami and Los Angeles because we wanted to also have very large cities but what was really important to us in that choice was that they had very different political And we really wanted to look at how the societal level, that outer layer of the external environment, if you go back to the National Academies model, how different policies in that level might trickle down and affect physicians at the individual level. And it did seem to make a difference because physicians in LA referenced kind of the sort of more favorable policies from their governor and also people in their local community in Los Angeles really taking the pandemic seriously, whereas that was not the case in Miami and we heard a lot kind of about about the state governor and about the way that COVID was playing out in the state of Florida and also about tourists, you know, coming in and bringing COVID into their hospitals and affecting their workloads and and so some of those comparisons were really fruitful as well. Outstanding. Thank you. And just to give everybody kind of a heads up, we have about four minutes left, so we'll go through maybe two or three more questions. Next question is, how will you follow up with organizations to see that changes are made? This is just kind of a general question. Yeah, I'm happy to provide kind of our approach, you know, of how we're going to do this. You know, so after the intervention takes place, and our first, you know, it's designed and we are into the implementation, our first follow through is to look at the adoption and the fidelity of that intervention. That's how we actually first follow through. So we have a measurement, you know, of how we're going to do this. So that's the first one. We provide feedback, you know, with the hope that if we do what's intended in terms of intervention, and that went well, we can expect the results. So that's number one. And the second, second approach post, in our case, we will use abbreviated survey only for, which will be a custom survey. So we will look at, you know, how we're going to do this. So that's the first one. We provide feedback, you know, with the hope that if we do what's intended in terms of intervention, and that went well, we can expect the results. So that's number one. And the second, second approach post, in our case, we will use abbreviated survey only for, which will be a customized from the original one, in terms of just the amount of questions so that we can really study the intervention so that if there are specific factors that are being like moral distress, we'll definitely focus more of asking survey questions about moral distress. And then we're going to have focus groups, and we're going to be going on site again to collect those contextual data to be able to understand if people really believe that there is a change in a system. Um, yeah, I mean, this is a, this is the million dollar question and it's so hard for me to answer because we, you know, we didn't have an intervention based study, we came up with this set of recommendations that we really wanted to be actionable and we really struggled over what that meant, and how to kind of think about that we worked with an expert advisory board to come up with these recommendations. With really multidisciplinary expertise, and everyone sort of uniformly said the C-suite is not going to listen the C-suite is not going to going to listen and that's why we ended up targeting our recommendations to chief wellness officers instead. But I think it's really challenging to sort of think about how, how we measure the impact of these kinds of recommendations and what sort of a difference they might make and, and that's something that I think we're still working on, to be honest. do this, efforts, for example that people do recognize that they would like to have better chairs, and I'm really bringing up this very practical little things. Suddenly there is budget for chairs, and then you talk that there's a little bit of a work to kind of design maybe one part of the unit and redesign it quickly repaint it right so like those engineering immediate things and suddenly we have the money somehow everything aligns and we are able to do it. I've seen hundreds of these type of a little grassroots efforts to be able to align people and get it done. And I think that is the first step right showing people some love, showing people that we are here for you, and we want to make this change immediately right and really knowing that the leaders want to do the best as well right they dealing with a lot of other problems you know budget cuts were currently, you know, trying to kind of solve a lot of issues by being able to integrate together with this tremendous people that we have in our organizations. There is hope and I know it sounds daunting, but I do see a lot of positivity that we can you know that can affect people so I just want to leave you with that thought that you know we there is there's truly hope to get this to get better. Okay, and that actually brings us right to the one o'clock hour so I do appreciate the outstanding conversation. Thank you so much for your expertise today and taking time out of your busy schedules. This is a great topic and definitely generated a lot of questions a lot of feedback. Thank you both very very much to all of our attendees who attended live today, you will receive a link to the archive recording, as well as a copy of the slides and how to claim your credit. If you did not attend live, you will receive a link to the archive presentation and a copy of the slides. Thank you everyone so much for joining us for taking time out of your day and wish everybody well. Thank you.

COVID-19 pandemic

healthcare workers

systems perspective

physicians

stress and burnout

institutional disparities

trust in science

chief wellness officers

interventions

healthcare systems