Hello, everyone. My name is Arti Sekar, and I'm a practicing radiologist at Emory University, and we are delighted to have you here today to talk about burnout and wellness and lots of other great topics. I'd like to take a few moments right now to go over a few items before we get started. This webinar is being recorded and will be available on demand next week in the RS&A Online Learning Center. You will also have access to a supplemental resource guide that includes recommended readings on physician burnout and wellness and implementation strategies. There will be time for the audience to ask questions after the presentations. We want this to be engaging and interactive, so please submit your questions in the Q&A box, and you can also use the chat box to interact with other participants, as well as Dr. Parikh and myself. The following slides include important CME information. Please take a moment to read each slide to yourself. So, claiming CME credit. To gain CME credit, be sure to click the link in the resources panel to complete the survey to receive credit for your participation. The webinar offers one AMA PRA Category 1 credit for CME. Next slide. The disclosure statement. Please review the disclosure and accreditation statement. Next slide. The accreditation and designation statement. Please review this as well. Next slide. Please review the RS&A disclaimer statement. And lastly, please review our learning objective for today's webinar. Okay, let's get started. So, today, Dr. Parikh and I will discuss physician burnout amongst radiologists and wellness, as well as micro habits you can adopt to better cope with work-related stressors. We want this to be an interactive webinar, so please submit your questions in the Q&A box, and we will address them after our presentations. We will now start with a presentation from Dr. Parikh. Hello, everybody. Over the next 25 minutes or so, we're going to be discussing beating the burn and navigating radiology practice challenges. I have no relevant conflicts to disclose. I would like to start off by thanking the RS and the organizing committee for the honor of being able to present today. A special thanks to Ms. Kimberly Cambridge, who actually organized and coordinated all this, and I am sincerely honored to be able to share the podium virtually today with Dr. Sekhar. So, what we're going to start with, first of all, is clarification of what the terms burnout and wellness, etc., mean, because it's used colloquially and there's a lot of confusion about what these terms are actually described as. The World Health Organization has now clarified for everybody what burnout is. It is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. And yes, we all have stresses outside the home that we deal with, but I want to emphasize that this is workplace-related. In fact, the World Health Organization goes on to specify that this is a phenomenon in the occupational context. It should not be applied to describe experiences in other areas of life. So, things like raising parents or raising children, which are stresses we deal with outside of our workplace, are important, but don't really contribute necessarily to burnout, which is occupationally related. Now, what is actually burnout? Burnout has three dimensions that actually are used to define burnout. The first one is that of emotional exhaustion, where individuals start to feel a little bit overextended and they feel depleted in terms of being able to do physical and emotional abilities for tasks. Secondly, they start to feel depersonalized, so they're detached and start to become cynical. Lastly, there's the reduced personal accomplishment dimension, where people start to feel inadequate and ineffective. I'm often asked at national and international meetings the difference between burnout and depression, and following the lead of Dr. Rebecca Brandel at the President of the American Psychiatric Association years ago, one of the ways that we can distinguish between burnout and depression is PTO. When you take vacation time or a mental health day, you should feel re-energized and your battery should feel recharged. If it does not, there may be a possibility that we're dealing with depression as opposed to burnout, and the consequences can be significantly more severe for depression. As a mental health advocate, if you are experiencing that sort of situation, please try and seek help. Now, what is health versus wellness? The World Health Organization basically implies that health can be defined as a state of complete, and I stress complete, physical, mental, and social well-being, and not just merely the absence of disease or infirmity. Wellness goes beyond that. Wellness is talking about a quality of life. That is the most important dimension of wellness, which includes not just the absence of ill-being, but the presence, and I say not just complete, but positive physical, mental, social, and integrated well-being. Wellness, as opposed to burnout, does extend across personal and work-life domains. Here's this model where we can look at right now. Let's take an individual made up of four specific constructs, the mental, the occupational, the physical, and the social. In this model, we can see all of these are intact. Ideally, you could say, well, the person is well, but not really. In this model, they're healthy because they're not integrated. In wellness, we actually have integration of all these four constructs. Ultimately, what we want to achieve is that central core moment where all of these are integrated well to create what in historic Asian culture has been referred to as the zen. One example of a close to zen moment, if all of you who are physicians on the line were to close your eyes right now and think about that magical moment when you opened up that email or letter when you got into medical school and how you felt at that moment, and then if you were to open your eyes and feel about where you are now, the question should come into your mind, why are things different now? You achieved everything you wanted to do by climbing the top of the mountain and achieving that zen. That actually dovetails into some of the conversations we're going to have today. In this model, burnout specifically affects here, the occupational context. In the occupational context, that is the construct that is affected by burnout. Over time, the equilibration of the whole well-being can be affected by chronic burnout and ultimately can displace our wellness. Now, I'll start out that somebody has taken a lot of criticism for doing research in burnout. There are unknowns. I'll just be upfront about that. We don't know the pathophysiology of burnout. We don't know the origins, the prevention, and how to treat it. I think we can all agree with this statement, but it's actually written by one of the critics, that there is clearly something important and worrisome happening to overall physician well-being. Speculation about its causes is a worthy place to start in developing hypotheses that can ultimately lead to solutions. Now that we've defined burnout versus wellness versus health, let's talk, Lex, about why burnout is relevant. Does it really apply to radiology? First of all, is there burnout in radiology? Well, I'm going to look at studies from multiple specialties now. In musculoskeletal, the study that was done using validated metrics showed about an 80% plus prevalence of burnout across the specialty. In neuroradiology, 49% to 75%. In pediatric radiology, 61% to 66%. In cardiothoracics, 84% to 88%. In breast, and I'd like to acknowledge my co-authors and my collaborators, Dr. Minero and Dr. Sun, 78.4%. And interventional, 71.9%. Now, the range is from 50% to 80% of burnout, which is pretty significant. But I want to point out that all these studies were done by independent teams, independent collaborators, using independent subspecialty cohorts, going through independent peer-reviewed processes with independent journals. In summary, the breadth and depth of research does support the prevalence of burnout across radiology. Moreover, the nice thing about actually separating out the individual components of burnout is we can see which dimensions seem to be more prevalent. For example, this study in breast showed that we seem to have more purpose and reduced personal accomplishment is not as prevalent as other components of burnout, as we'll talk about. And we'll return to purpose later in this conversation. Now, why even discuss burnout? Yes, it may be prevalent, but are there associations with it? The answer is yes. In summary, we can look at it in three dimensions. First of all, burnout and physician has been associated and linked with patient care issues, lower quality of patient care, medical errors, increased recovery time from procedures, and lower patient satisfaction scores. Secondly, health systems are affected with lower productivity, increased turnover of staff, reduced access from patients, and increased cost to the healthcare system. And this shared approach and model is what will be important when we discuss this with our administrators and leaders in physician health systems. Lastly, and arguably most importantly to physicians, is the individual health of the physician. Burnout has been linked with substance abuse, depression, suicide, and overall poor self-care. So how do we actually start rewriting the narrative with respect to burnout? How do we transition from burnout to actual brilliance? Well, let's dissect the components and factors that actually affect burnout. In this model, which has been adapted by the AMA, the American Medical Association, assuming an individual has core meaning at work, then there are six potential drivers that actually contribute to burnout. Workload, control and flexibility, work-life integration, social support, organizational culture, and efficiency. As these are less optimal, that contributes to the dimensions of burnout. But equally important is that if we have more optimal circumstances, then there can be engagement, vigor, dedication, and absorption. All the things we're hoping to seek for in our practice. So how do we actually move the needle towards professional fulfillment? Well, we have to thank our colleagues at Stanford for this wonderful model, which demonstrates that there are basically three components that contribute to professional fulfillment. Cultural wellness, and efficiency of practice, and personal resilience. And for the remainder of this session, we'll be talking about all three. So let's start with resilience. And I'm going to keep my comments minimal because Dr. Sekar will take over in her section to talk more about this. But in the model of wellness with central core, where we have social wellness, wellness of mind, and physical wellness, we can see this blue ring potentially demonstrating resilience. And the thicker the resilience, the more we're able to actually absorb the stresses from external sources. I want to point out the resilience is not just pointing back, it's the collection of personal qualities that enable us to not even adapt, but potentially even thrive in the face of adversity and stress. Meta-analysis has been carried out, for example, this one in Lancet that looked at multiple studies that contributed to actually intervene interventions to help burnout. And what they showed overall was we're able to reduce burnout in a prevalence of population. Overall, both individual focused and structural organizational strategies can result in clinically meaning reductions in burnout. So again, I want to emphasize that the resiliency component is important, but I think we should look at the overall data as well. This study looked at resilience across physicians, over 5,000 physicians. And physicians had significantly higher resilience scores in the general United employed US population. That sort of makes sense intuitively as physicians, because if you think about the brutality of medical school, internship, and then residency, how much we go through. Higher resilience scores were associated with lower burnout rates, but even the most resilient physicians had substantial rates of burnout. This implies that although maintaining and strengthening resilience is important, physicians overall do not have a deficit in resilience. Higher additional solutions, including efforts to address system issues, are needed to really produce burnout and promote physician well-being. In summary, we need to stop just focusing on redesigning our radiologists as people, but start thinking overall system-wise at redesigning the work process. So let's talk about the second component of the Stanford model, culture. And how do we approach that? Well, thanks to nice pioneering work by Dr. Schoenfeld and colleagues at the Mayo Clinic, what we're able to see is that there are multiple components that actually can be looked at. And we're going to focus on a few of these over the next few minutes. So first of all, we're going to look at harnessing the power of leadership. If we look at the impact of organizational leadership on physician burnout satisfaction, this study was over 2,800 physicians and scientists using validated tools showed that the respondents were actually going to rate their physician leaders in terms of their immediate supervisors in terms of how well they thought their leaders performed. And these are the questions that were asked. My career has developmental conversations with me. My leader has career developmental conversations with me. My leader inspires me to do my best. My leader empowers me. My leader is interested in my opinion. My leader encourages employee ideas. My leader treats me with respect and dignity. My leader provides feedback and coaching. My leader recognizes me. My leader keeps me informed about changes. My leader encourages me to develop. I would recommend working for this leader. Overall, I am satisfied with this leader. I think for many of us, many of these 12 questions really resonate with us. And in fact, this leadership index is now has been validated and being used by the Physician Wellness Academic Consortium here in the United States. What they're able to show in the famous study from Mayo is that for every one point increase in leadership score, there was a 3.3% decrease in likelihood of burnout and a 9% increase in job satisfaction. Therefore, the authors conclude the leadership qualities of physician supervisors appear to impact the well-being and satisfaction of individual physicians. If we look at actual practice leaders, 55% of respondents say that they agree that burnout is an extremely or very significant problem and 22% reported that burnout is a significant problem. So three out of four acknowledge that of our leaders based on this study across the United States, that burnout is either an extremely or very significant problem. At the same time, only 19% of respondents said they had mechanisms to assess physician burnout. 21% said they were extremely or very effective in addressing physician burnout. But altogether, what we're seeing is this trend that leadership can either cause or potentially be the cure of burnout in radiology. But before we become too harsh on our leaders, let's understand the leaders themselves and what they're going through. Here's this study that was carried out at Stanford that actually looked at the leadership score of the actual leaders versus their burnout as leaders. And what we're able to see here is the professional fulfillment score of leaders versus their leadership score. And we can see the trend that the more leaders were burnt out, the lesser leadership score, the more fulfilled they were, the higher the leadership score. In fact, every one point increase in burnout for the leaders was associated with a 0.19 decrement leadership behavior score. In summary, the authors conclude that burnout, professional fulfillment, and self-care practices of physician leaders were associated with their independently assessed leadership effectiveness. We have to think about how we can actually manage the burnout of leaders if we're going to affect positively the actual burnout of physicians. Now, a couple of studies we've done at MD Anderson, we looked at actual using professional development of our leaders to see what outcomes could be done. In our limited time, we don't have time to go through all the data, but suffice it to say that what we're able to show is that formal wellness training of academic radiology leaders improve teamwork scores that are faculty. And similarly, formal wellness training of academic radiology leaders improve the work-life conflict of leaders. This is a first step, and hopefully this will be repeated and carried out in multiple other institutions. We're able to show that professional development of leaders can positively affect the culture. I'm often asked by leaders, how do you actually start? Where do you go with this if you want to address burnout? And I tell them about the ABC. A is action. Action meaning accept that this is happening, acknowledge that this has to be addressed, and start to address it. You do that by first of all doing measurements of burnout. Ideally, it could be using objective validated metrics, either internally or by an external source, but even focus groups is a good start. The second thing that needs to happen is the B, which is to make a business case. And it costs, according to the AMA estimates, anywhere from $250,000 to $1 million to cost to replace the MD. In fact, on the website, they acknowledge, which most of us use as a rule of thumb, that it costs two, double to three times the actual annual physician's salary to replace a physician. And that includes both recruitment costs, sign-on bonuses, loss billing, added costs, basically both direct and indirect costs. The next thing we can do is then collaborate. And what that means is that physician leaders need to collaborate with their system leaders or their leaders above them to explain that there is a shared objective here, not just for the benefit of the physician, that's not an important argument, but this is a patient care issue, which most leadership and organizations and physicians alike say is important, that we want to improve quality of care, that we want to reduce errors. We also want to help our health system by reducing unnecessary turnover, reducing costs, and actually increasing productivity. So what does the leader do next? The next thing they can do is actually cultivate community. Social isolation and loneliness are linked with multiple outcomes, including depression, sleep fragmentation, reduced impulse control, deterioration cognitively, and dementia, all things we don't want to see. So what we can do is we can actually go out as leaders and get to know our individual teams, learn the unique skill sets of our physicians. Studies have shown that as a physician spends 20% of the professional effort focused on meaningful dimensions in their career, that can help to reduce their burnout. So leaders can therefore afterwards leverage resources, whether that's funding, protective time, sponsorship, professional development to help support the development of their physician. Recognition is more than just the physician's stroke of their egos. Recognition is increasing social acceptance of physicians. Emails of good pickups, metrics of acknowledgement, blast emails, acknowledging individual success stories are all things that can be done to help. The physician leaders can also be a role model by rounding and meeting with their physicians, attending social events when they have, pledging their own individual self-care and saying that it's important for them to look at the self-care of their physicians, and then using facilitated groups potentially to gain commensality. This study from the Mayo Clinic, which used 74 physicians and randomized 37 allocated to the intervention group, 37 allocated to the control group. The intervention was actually trying to promote well-being by using 19 bi-weekly facilitated physician discussion groups over nine months. The rates of depersonalization, emotional exhaustion, overall burnout decreased substantially interventional harm. And what was even more impressive is that was sustained at 12 months. So community field does matter. Next thing we can do culturally is look at work-life integration. One of the things we can do to help identify what are the stressors we want to address is to ask our individual physicians or across the country, we can ask cohorts. For example, this in breast radiology showed that the number two stressor was work balance and the number six stressor was actually dealing with dependent care. Well, a study from the JACR that was published in 2017, looked at the distribution of lactation facilities and practices, and only 13% at that time had lactation facilities. And given the number of women now that are increasing in radiology and to treat them with respect and dignity, advocating and supporting the implementation of private lactation facilities is one step leaders can take to move forward with trying to address the stresses. Similarly, in terms of helping work-life balance, it's important for leaders to understand now that FML is no longer just a gender issue. It is a practice issue. On three separate studies, the ACR Commission on Human Resources has shown that there is a significant use of FML by males and females. And so understanding that is important for leaders to understand the importance of FML. A recent study of private practice leaders showed that very much a small minority of private practice leaders actually understands FML. There's another step that can be taken in terms of promoting work-life integration. Next, I want to move on towards self-care. One of the most iconic studies that was carried out in the wellness space is looking at cell valuation that was carried out after Dr. McIntryck and colleagues at Mayo and published in the Mayo Clinic Proceedings. The clinician cell valuation scale is a four-item scale that assesses both deferment of self-care, but also the personal harsh response, the personal imperfections and errors. And this study was carried out in five academic medical centers with almost 3,900 physicians who responded. And what we can see is this graph, that the more that the individual physicians can value themselves and respond themselves in a positive way to harsh imperfections, the more they were able to do that, the lower the burnout score. The lower their self-value score, the higher their burnout. This inverse relationship was highly significant. And so what that means is things like hours of work, sleep, exercise and days off matter. In a study that was carried out, for example, with prevalence of burnout of radiologists in private practice, almost half were burnt out, maybe even more disheartening, almost a quarter were unprofessionally fulfilled, or only a quarter were professionally fulfilled, almost three quarters were not. There was a strong inverse association between professional fulfillment and burnout, which was highly significant. But what was even more interesting was that specifically significant associated professional fulfillment of the private practice physicians were eating nutrition meals and exercising at least four times a week. Again, in radiology, self-care does seem to matter. Also, we know that the number three stressor for breast imagers is lawsuits, and this has been shown in other specialty cohorts as well. So one of the things we implemented, for example, at MD Anderson, which has been well-received by physicians, is the Peer Practice Resistance Committee. So when physicians undergo and experience a serious adverse event, we recognize that the first victim may be the patient, but the second victim is our physician. So reaching out and supporting them as peers is well-received. Now that we've talked about culture, in the next few minutes, I'd like to wrap up with a few comments about operations that can be carried out, operational improvements. So far, in terms of the drivers of burnout, we've looked at things like control, work life, social support, organizational culture. In the next five minutes or so, I'm going to talk briefly about some of the operational things to look at, including workload and efficiency and job resources. So first of all, how do we better go about managing workload? And again, the breast radiology survey shows that practicing faster was the number one stressor that most breast radiologists were experiencing. It's important, first of all, to understand the difference between efficiency and speed. Efficiency means that we are trying, and most radiologists like this idea, of being able to use their time on things that fulfill their central purpose, which is to take care of patients. It means less time on things that can be either allocated to other people, or they shouldn't be spending time at all. Efficiency is different speed. The higher the speed you go, you can only go faster and faster on the hamster wheel before ultimately you collapse. Ultimately, speed will kill. So how do we increase efficiency? Some basic principles. Scheduling should be structured in a way to try and make sure that the radiologist is not hyperspressed at any given moment. Having outside priors available, meta-analysis has shown that having the priors on the history both can improve the actual quality of care, which then translates to the radiologist feeling like they have a higher purpose. Internal priors, reducing unnecessary interruptions, and potentially using extenders, which we'll come back to. Now, workflow also means not just having a schedule, but a realistic schedule and a consistent schedule, where there's level loading of work across the enterprise, across it. And if there is cherry picking, that needs to be addressed by the leadership right away to make sure that all physicians feel like they're equally contributing. It's a revolutionary shift that we need to have across healthcare, where we need to move away from the mantra of no margin, no mission, to what COVID has taught us. When you have no people, you have no mission. Our physicians are important values that need to be looked at from the enterprise. Historically, many organizations use metrics from the AAA, RAD, and MGMA. I realize we have an international audience, so AAA, RAD, recurs in the Association of Administrators in Academic Radiology. And the MGMA, which uses those metrics for productivity and private practice predominantly, stands for the Medical Group Management Association. The problem with this is everybody tries to not only beat the benchmarks, but ultimately achieve them. So ultimately, this cyclical inflation to the point that it cannot be achieved. So it's important for leaders to understand that these are just metrics and to adapt them to the local environment. Finance is the next thing we're going to talk about. First of all, it's important to establish a culture of fair compensation. What does that mean? That's going to be local, because it's going to vary by clinical volume, leadership, research, seniority, clinical case complexity. But it's important to be proactive and transparent about what the compensation would be. And ideally, that should be done at the time of recruiting and boarding. Physicians feel like they're part of a process that's very transparent. There are opportunities, for example, to be able to, with the buy-in of the whole group, to be able to implement finances in a way that can help the group. If a group is short-staffed, using signing bonuses can be used to help new recruits offset their medical school expenses and be a win-win for the practice and the individual coming on board. If for whatever reason you're not able to hire and the practice has a higher bonus or the hospital system has a higher productivity in terms of RVUs and in terms of income, it'd be nice to be able to share that as retention bonuses. Many groups are also now funding fellowships to be able to address shortages as well. Operational strategies, it's important to make sure we look at scheduling flexibility. There are different ways to do this. For example, individuals may want to work early or late shifts and groups can work together to make sure people work where they feel most comfortable. There are sometimes high-value days for some radiologists, not necessarily applying to other radiologists. For example, for younger radiologists earlier in their career, and I can attest to this, having spring break was a big deal to be able to spend time with kids. That becomes less important later on and maybe things can be worked out so we can trade to help each other out. Bunker shifts talks about extra voluntary read-only shifts, which some people may want to do and other people may be less inclined to do. Remote reading is being used more and more as well. At Anderson, in terms of four actual operational steps we've done, we've implemented remote workstations. We're adjusting our shift hours in many of our rotations. In MRIs, where we have some of the most complex and breast MRs in the country or internationally, and then we stop at a certain time and say they can be read the next day and our clinicians understand that. Looking at more and more opportunities for part-time help. Operational strategy number four we're going to look at is using support staffing. These are different individuals that can help offset some of the stresses that physicians feel so that they can spend more time on the things that they find more central to their purpose and other people can't do. Reading room assistants, for example, can help obtain and upload both the reports into the PACS network in advance of patient registration to help improve radiology workflow. Radiology call assistants who can initiate answer route messages, gather and process clinical information, take care of pre-hanging protocols, et cetera, can really be a wonderful balloon for radiology. Advanced practice providers who can help cover contrast coverage, for example, and non-emergent situations to the very least can help offset physician time. Nurse navigators can be critical in terms of dealing with issues, for example, like financial support for patients who come in for oncology care in advance. Lastly, a few minutes about talking about leveraging IT. I just want to point out that, you know, there are multiple information systems that we deal with radiology. Radiology information system, the PAC, the voice recognition, the data flow ideally should be seamless and it is, unfortunately, the infrastructures are very primitive and inflexible. Our primary hurdle is not each other, but complexity, and so the primary solution needs to be standardization. It's important for us to work with our IT because IT has the opportunity to be able to do better than we can, things like process, calculating, organizing, displaying data, and this non-clinical sphere is probably where AI would help us the most. We have the opportunity, though, with physicians to be involved as the architect because we have the ability to do critical things, problem solve and interact. Ultimately, the value stream, which talks about in manufacturing the path a product takes through to ultimately achieve the product, is actually, I define the radiology by two ways, our image report and our image quality, and so we have the opportunity to link things like order entry to history. You have the standardized imaging protocols that are triggered by the order entry, program hanging protocols that are then carried out because the order entry coupled with the standardized imaging protocols is ultimately the infrastructure reporting. All these can help improve our workflow. In the end, what we're talking about is transitioning from the triple aim to the quadruple aim where the care of the patient requires care of the provider. Ultimately, what we're talking about in the triple aim ultimately that was introduced by Dr. Berwick and Collins is looking at better outcomes, lower costs, and improved patient care, which was ultimately used as a north star for healthcare improvement when introduced in 2008. The quadruple aim talks about also looking at clinician well-being. When we look at all these operational strategies, what does this mean? Ultimately, people ask me, how do I start? How do I start? How do I start? And I come back to this article, not because I'm a co-author, but because we spend so much time, hundreds of hours, all of us putting this together, you're stripping literature. I want to acknowledge Dr. Harrell, who was first off on this, that the nine pillars that we need to look at when we're talking about burnout is adequate staffing, appropriate scheduling, restoring control to our physicians, reducing call, having balanced lifestyle, improving efficiency, managing our finances to realistic expectations, reducing isolation, and helping our physicians when they have mental health issues. Ultimately, what we want to do is look at burnout as an iceberg for many reasons. We want to chip away at this iceberg slowly because this burnout issue did not happen overnight. It's been going on for decades. And we want to do it slowly because the opposite of just exploding everything doesn't make sense. We need to still be there to look after our physicians. We don't want to explode healthcare. And the other reason for looking at it as an iceberg is when you see somebody experiencing burnout, think about the fact that we're not just talking about the individual. Sometimes what we need to look at is understand that there is a bigger issue. We need to not only look at the disease, but address the symptoms. I wish you well in your quest from burnout to brilliance. Thank you for your attention. Thank you so much, Dr. Parikh, for that amazing talk. And I learned a lot. I'm now going to be talking about the science of happiness and microhabits for wellness. I have no financial disclosures. These are my kids, Uma and Gigi. They're two and one years old, so they are my motivation to be well and to have more work-life integration these days. My learning objectives are to discuss the science of happiness, explore the concept of microhabits, and discuss six areas to cultivate microhabits for life and work. As Dr. Parikh just eloquently described in great detail, many of us are feeling burnt out. And there are many, many factors, including the high clinical workload and isolation. And a lot of the solutions are proper staffing, having emotionally intelligent leaders, flexibility. A lot of them are described very nicely in this Mayo Clinic Strategies for Burnout book. Many of these factors are out of our control. I'm not the chair of the department. I'm not even a division chief. What are the things that I can control in my life to help my well-being and my burnout? Focusing on what's in my control, I am using these two resources. During the pandemic, I took an online course, The Science of Well-Being, from the happiness professor at Yale, Dr. Lori Santos, and this book that I really love, Atomic Habits, which basically, the main point is that many of the things we do are out of habit, but it's very difficult to form new habits. So if we can chip, make them into micro habits or very, very small things that we do every day, that can be a more manageable way to start to address this problem. So I'm going to highlight some of the things I learned from The Science of Well-Being, and then some of the micro habit techniques for different areas that we might encounter in our work and life. So Dr. Santos first describes, you know, a lot of people, this is a very vague term, what is happiness, right? So she describes it as two different things. One is a feeling of pleasure and joy, like, are you happy in your life? Are you laughing a lot? Are you smiling? And the other is meaning and having purpose and living for something beyond yourself. Are you happy with your life? And I would say that we both, we all need both of these things in different proportions at different parts of our lives. And the important thing is to reflect upon where you are and what you need and how you can get more of that. So it's a combination of feeling joy and having meaning. Unfortunately, we have more now and are less happy than ever. From the 1940s until now, we've got more automation, access to everything at our fingertips. And yet there's an epidemic of depression, suicide, and loneliness. One of the reasons is that we don't think in absolutes. We're always comparing to reference points. So for example, silver Olympic winners are more unhappy than bronze winners because they see that they almost got the gold, whereas the bronze winners are like, well, I'm just happy to be on the podium. And we're always referring to ourselves. We always want more in the future. So we're never satisfied. This is just a glitch of human brains. And part of what we need to do is kind of take more time to reflect, be grateful for what we do have, and not always kind of just be running on that treadmill. That treadmill is called hedonic adaptation. We always get used to the new normal, and everything loses excitement over time. That shiny new car that you bought is going to be exciting at first, and eventually it's going to lose its appeal. One experiment that they did was they saw that lottery winners and paraplegics both come back to their baseline a year after a major event. So for even something that might be very happy or something that would be very stressful, we all come back to our baseline. So where does that baseline form? This is one of the theories about our happiness, which is that about 50% of it is set. It's in our genetics. Another 10% is our life circumstances, which I think people tend to overestimate. And we can see that in how people respond to the same event. So for example, my residents will always tell me, some of them will say, oh, I hate overnight call. It's horrible. And others will say, oh, I learned a lot. I like being independent. It's the same exact circumstance, and people are responding differently. And then a huge part of it is in our control. And this is what we want to talk about today. What are the things that we can do to shape how we respond to events, our resilience, what we think and what we do about it? And this is sort of the field of positive psychology. In the course, Dr. Santos went through different things that make us not as happy as predicted, unhappy, and things that can make us happier. So when you ask college students what they want in life, they'll say they want a good job. And then when you ask them what that is, they say, well, I want money and leisure time. Well, I would argue that a lot of radiologists have a decent amount of money and even plenty of leisure time, and yet we're burnt out and feeling unhappy. And there's a number of things that you would think would make you happier but don't necessarily do that. Things that make you, frankly, unhappy include social media and comparison. And there are a number of things that can make you happier, and I'll go through some of these in more detail, but including sleep, deep social connections, prioritizing time, gratitude, mindfulness, and flow state and growth mindset. So just to address some of the things I just talked about, so money, there was a large study of half a million Americans, and they showed that money can help you if you can't pay the bills, struggling to eat, those kinds of things. That can definitely make you happier in a sort of linear fashion. But at some point, it levels off and you don't necessarily become happier with more money. It can make you happier if you spend your money on experiences rather than material possessions because experiences are immune to hedonic adaptation. If you're out on a hike and the weather is changing and you don't know what's around the corner, you're not getting used to something that's just static in your house. Also if you spend money on other people, it actually makes you happier. You feel like a good person, that other person gives you a lot of gratitude back, and it actually makes you happier than if you just spend it on yourself. I am a huge advocate of financial independence, so I do always advise my trainees and younger colleagues to live lean when they're earlier in their careers. And this can give you more freedom and autonomy later on to maybe go part time, have greater choice in what you're going to do. So I do think it can mitigate burnout, but it doesn't linearly relate to happiness. Social media is actually just frankly can cause unhappiness because of the constant comparison. And just this week, the Surgeon General has been warning and saying that maybe we should have a warning label on social media because it particularly affects young adults, especially young women. So now on to things that make us happier. I love this book about sleep. Sleep is one of the most important things that can help your mood and your overall health. And I would highly recommend you to check this out if you're interested. Chronic sleep deprivation can lead to a lot of health problems. And I have a lot of doctors telling me like, oh, I don't need that much sleep or only five to six hours. And that's just not true. Most of us need seven to nine hours of sleep. So finding ways to prioritize that, to optimize your sleep is really important. Deep social connections, which I'll go into some strategies for this later in the talk. Extremely important. There was a 75-year longitudinal study. It was the largest study of men. So hopefully in the future, it'll include women. But what they found was the single most important thing for people's fulfillment and longevity was having good relationships. So having high quality relationships. It's not the number of friends, but the quality of your friendships and maintaining them over time. So there's one thing I'd really like to emphasize, which is that we really need to put more energy and effort into establishing and maintaining deep quality relationships. Time affluence. So people who prioritize time over money are happier. So be careful of moonlighting. It's a slippery slope. If you feel burnt out, but sometimes you're like, okay, well, if I'm going to work this hard, I might as well just work harder and make more money. That's not the solution. So I would encourage you to really think hard before you start signing up for more work. And consider part-time. I went to 80% before I even had kids. And that's just because I wanted to do other things that I'm interested in, like art and hiking and being in nature. Beware of time confetti. So we actually have more time now than ever. People are always saying, I'm so busy, I'm so busy. But we actually have more time than ever. So many things are automated. So many things are at our fingertips. But we split them into tiny pieces like time confetti because of distractions and interruptions. So then we have less time to do deeper work and be more creative. Mindfulness can decrease anxiety. So being fully in the present moment, not persevering on the past or thinking about the future. And it doesn't have to be meditation, although I love meditation. You can do it doing anything, cooking, just like when you're driving to work, actually paying attention to what's around you to the present moment. And finally, a concept that Dr. Santos described that I really love is going for flow. And this is where you're incrementally increasing your skill and challenges. So you can imagine if you have high challenges and low skill, like you're a first year radiology resident, you're going to have a lot of anxiety. Or if you have high skill and low challenge, you're going to be sort of bored and overly relaxed. And so she talks about kind of staying in this flow channel where you keep setting yourself like a little bigger goal, and then your skill will rise to meet that. In order to do that, though, you have to be not afraid of failure and something that I like, which is growth mindset. So there's no such thing as failure. Everything's an experiment. We're going to learn from the process and we're going to grow. An example of this, I made a radiology skirt. I didn't know if it was going to be successful. I didn't know how to do it, but I thought I'd give it a try. So I saw Cate Blanchett wearing this inspiration dress at Cannes. I took some of my favorite hepatobiliary cases. I put some color on it and made this file. I took it to Georgia Tech and got it printed on fabric. And then I spent a Saturday afternoon sewing it into a dress. I messed up on the pleats, I messed up on the pockets, but I asked for help and I learned a lot in the process. And now I have my radiology skirt. I take it to abdominal radiology meetings and I pimp my friends on all these cool biliary cases. And it's just a fun way to grow in an artistic way. So in summary about happiness, we need a balance of being happy in our life with lots of pleasure and joy and happy with our life with meaning. Unfortunately, as a society, we are unhappier than ever with epidemics of loneliness and depression. Some of the reasons are that we overestimate the impact of circumstances. We always compare to reference points, including ourselves in the past. And we have hedonic adaptation where we get used to everything. And we underestimate the power of our thoughts and our habits. So these are some of the things that make us happy. And now I'm going to talk about some of the micro habits, the concept of micro habits that we can sort of integrate into our lives to try to address some of these things. So what are habits? Well, habits are unconscious solutions to recurring problems. And these are very helpful. You can imagine if we walked into a room every time it was dark and we had to wonder what we're going to do about it, that would waste a lot of time. So we unconsciously just turn the lights on. But about 50% of our, if not more of our actions are done out of habit. We are very habitual creatures. Habits are formed by a cue that leads to a craving that we respond to when we get a reward. So for example, most of us brush our teeth because we have the cue of not tasting good when we wake up. We have this craving to get rid of that taste. And then the reward is feeling fresh afterwards. But it's very challenging to build new habits. Most of our habits are developed by our mid twenties. So micro habits is a way to start to build new habits in very small ways. And it can compound over time, just like investing in the stock market. So you could imagine if you wanted to do maybe 10 pushups, and you can't do 10 pushups today. If you start doing just one pushup a day, eventually you're going to get stronger. And then you're going to say, oh, I think I could do two pushups. And eventually that's going to become easier and you could do three. So just starting in very small ways, even if you just do it for two minutes a day, can actually really help you build that habit over time. Another key concept from this book is that true behavior change is identity change. So a lot of times we talk about goals or outcomes, like I want to run a marathon. But is that really your goal? A lot of times it's not. Maybe you want to become healthier, you want to be in nature. And so instead of focusing on goals, it's better to create lifelong habits, it's better to focus on our identity. So if your identity is I am a runner, every time you go for a run, you're sort of like putting in a, you know, like an investment into that identity. And it creates the lifelong habits that will feed that identity. So when I was thinking about my wellness at work and in life, you know, what is the identity that I want to create? And this will be different for everyone. And I would I would encourage you to make a mission statement for yourself. For me, I'm a curious lifelong learner who does excellent work and has meaningful relationships. That is the identity that I want to cultivate through my daily habits and through what I'm building. So I'm going to talk about six areas that we can use micro habits for life and work. The first is to build strong and meaningful relationships. As I mentioned, this is one of my big points I want to drive home today. I really think this is a huge mitigator against burnout, both at work and in your life. Creating gratitude, developing a strategy for lifelong learner. We're all lifelong learners and we need to sort of, you know, but it's it's hard to sort of know what to do after we graduate and take our boards. And now we're just, you know, on on the rest of our life by ourselves. Having strategies for accountability, designing our environment for success, both at home and at work, and automating and outsourcing. And finally, a really important final habit is to reflect upon what you're doing, how well it went, and to revise your strategy for the future. So building strong and meaningful relationships. This is a recent picture of my section at a journal club that was at my my section chief, Dr. Courtney Moreno's house. It was a Thursday night at 8 p.m. and you can see from all these smiling faces that we have great culture. A huge part of that is having emotionally intelligent leadership, as Dr. Parikh talked about extensively, which Dr. Moreno is. But another huge part of it is showing up in person. You know, it's very easy to just zoom it in or, you know, not show up. But I would really encourage you to do that. This was a, you know, a weeknight. A lot of us have young kids and we all made sure that we had child care so that we could show up in person. I would encourage you also to ask better questions of each other. So, you know, say you go to lunch with one of your colleagues and you might say, like, how was your call over the weekend? But a better question or a deeper question to get to know them better might be, you know, what fulfills you or what made you go into medicine? One of my favorite questions is, tell me your life story in five minutes. And I can't tell you how much I've learned about people that I've known for years by asking them that question. There were so many parts along their pathway that I didn't know about that are really important and foundational to them that I learned through that question. And follow up and follow through. So, you know, just send a quick text message of gratitude afterwards, like, that was a great presentation or it was really wonderful to spend time with you. Here's a great photo of us from this event and sort of emphasize those relationships. I would also encourage you to cultivate relationships outside of your little, you know, your section and your world. Here's one of my surgical oncologists and we did a triathlon together because he invited me to do this with him and we got to bond and learn more about each other in this way. And here are some of my friends from the Society of Abdominal Radiology. Our gold medal winner, Dr. Giovanna, Leila. I would encourage you to reach out to people at other institutions. They can really open your mind and perspective. And you know, little ways you can do this, little micro habit you can do is just sending people a quick message after their talk. I loved your talk. Do you mind, you know, could we talk, could we grab coffee or could we talk on the phone? I'd love to pick your mind about your career and your life and how it is that you made that PowerPoint presentation. And people love to, you know, be reached out to and they'll be very responsive to, you know, developing a relationship with you. This is some strategies for just cultivating friendships that I really like. So friendships apparently need three things. One is positivity. So if it's just based on complaining about work, this relationship probably won't last. Another is consistency. So this is where small, small little things like a little text message that is personal, like, oh, I saw this article reminded me of what you were talking about. Planning a phone catch up, putting dates on the calendar, like, oh, not just grab lunch, but like, let's put it on the calendar. What day are you free? And plan meaningful experiences to have together. And also vulnerability. So don't be afraid to cry and share failures. Ask your deeper questions and really listen to other people. Okay, next is cultivating an attitude of gratitude. So I know there's a lot of, you know, buzzword, it's kind of a buzzword right now, but gratitude is so important. We all want to feel valued and most of us got a lot of positive validation our whole lives and now we get very little. But it becomes infectious and it really helps, you know, with the positivity that you can bring to your group. So here are some small little things you can do to express gratitude. You don't have to say thank you. You can just do small little things like greeting people when you get to work and thanking team members at the end of the day. Being authentic and vulnerable. So your trainees do not expect you to be perfect and know everything, and in fact, they can learn the most from you telling them, you know, your mistakes or things that you've learned from. And being curious about their lives. Here I am taking some of my trainees on a walk or a stair climb and showing that I'm really invested in them as humans. Tell your referring physicians, thank you so much for calling me. You know, that means your value to them. You're an important part of the team. Write to a person's section chief or chair about a job well done. If you go to a national meeting and somebody did a great job, write a little note to their chair. That means a huge amount, especially for junior members. And consider writing handwritten notes if you have something more meaningful that you would like to express to somebody. People really appreciate it. The highest functioning teams have a very high positive comment ratio. So when you're in a meeting, giving people, other people, micro doses of positivity can really help. So saying that's a terrific idea, nodding, smiling, even emojis can really help. Negative comments like that won't work or we shouldn't even consider that can really deflate the team and lead to people being less engaged. Just develop a strategy for lifelong learning. My favorite daily micro habit is keeping a case log. So I keep track of most of my cases and are many of my interesting cases. And after 13 years as an attending, I have 9000 cases, many with pathology follow up. I just have this HIPAA compliant Excel sheet open. I just add cases in as the day goes on. I follow them up once a week. And then I close the loop and, you know, send follow up emails to my to my surgeons. And we have a great symbiotic relationship. They're there. They appreciate when I say, hey, I was wrong and you were right. And I learned so much from this. And they start feeding me back like, oh, look at this interesting case, et cetera. I also use my case log to do a lot of little micro teaching throughout the day, and I believe teaching is learning. So for me, it's a really great strategy for lifelong learning. Accountability, so most of us are not good at being that accountable, so we need accountability structures. So find partners that can hold you accountable. This is my friend Talia. We go running together sometimes at six, six in the morning. If it's raining, she tells me to put on my raincoat. So you want to befriend people who have great habits, people you admire, because you will rise to the level of their habits. They can hold you accountable. I also love putting it on the calendar. So I wanted to read more books, so I joined a couple of book clubs. I do, I help lead a case conference every week. I've got my runs on the calendar. I might, you know, before a presentation, do a PowerPoint run through with my mentor, put it on the calendar. If it's on the calendar, it's going to happen. This is just a snapshot of our National Weekly Case Conference. We've posted to YouTube for the past six years. It's a way that I've been able to learn every single week. And, and it's, it's just a small, informal, you know, session, but it reaches a lot of people through YouTube. So it's a great habit that we've developed. Design your environment for success. So make good cues obvious. I wanted to ride my bikes more, so I took them out of my garage and put them in my dining room. If you want to run, maybe have your running shoes and your water ready to go out the door. I love Marie Kondo and Kon Marie-ing my place. So, you know, I basically love to take everything of one category out and put it in the right place so that you only have to tidy, you know, every five years or so, and everything has a specific place it's supposed to be, and you want to make cues for bad habits invisible. So, you know, consider taking the TV out of your bedroom or not having junk food at home. Your work environment too. I mean, consider having standing desks and make it as ergonomic and efficient as possible. Maybe with healthy snacks and water available. So your environment around you, you're designing it purposely so that you will be optimize your wellbeing. I'm just going to skip this. And then finally, just automating and outsourcing. I have hired personal assistants for many years and I love our reading room coordinators. They help us, Dr. Parikh touched upon this, but really being, you know, it takes some effort. You have to sort of make your expectations clear, train them on exactly, you know, what job needs to be done for the entire team, and once they're engaged, they can be super, super helpful for you and your colleagues, and the final micro habit is to reflect, so think about what, you know, how things felt, what can, what you can do better next time. How, who can you express gratitude towards and try to visualize things you want for the future. You know, what new skills do I want to acquire and what am I passionate about now? And this needs a growth mindset, as I mentioned before. So I showed you an example of me making a skirt, but here's my, one of my mentors, Susan Asher, who has retired from radiology and is now taking undergrad classes at Harvard, my residency classmate, Mary Ellen's son, who is a part-time radiologist and a farmer at her family farm, and Matt Davenport, the vice chair at university of Michigan, who in his free time, aside from doing lots of great work is released an album of his original songs on Spotify. So here are some things that make us happy and habits can help you get there by building strong and meaningful relationships, showing up in person and being consistent and vulnerable, practicing gratitude by being curious, asking deeper questions and having, giving small little micro doses of positivity to your team, developing a strategy for lifelong learning. My favorite strategy is my case log, having accountability partners and putting things on the calendar, designing your environment for success with good cues that you can see and automating and outsourcing and finally reflecting. I'm going to look at the chat now. Thank you so much for your attention. And we, we just have a few minutes left. I'm sorry that we went a little over, but I would love to hear any of your observations or responses or questions. Okay. Sounds like you guys are all on your road to wellness. Dr. Preet, do you have any final comments before we wrap up? No, I just want to say I really enjoyed your presentation, Dr. Sekhar, I learned a lot from you. And I would just like to say that, you know, it's nice to see like the transition of conversation over the last decade with expert out for not being accepted to something we were starting to increasingly understand the scientific investigate. There's a lot of healing that needs to happen in our profession. And just wanted to remind everybody, be compassionate to your patients. You've always been to your colleagues more and more, and especially to yourself. I think that will go a long way. Beautifully stated. Okay. Well, thank you again for joining and participating in the webinar. Please click, be sure to click the link in the resources panel to complete the survey and gain CME credit for your participation. You will receive a notification email from RSNA next week when the recording and resource guide are available at the RSNA online learning center. We hope that you have learned more about the causes and prevalence of physician burnout and some techniques to help you better cope and manage work-related stress, and be sure to check the RSNA website for upcoming educational events and webinars. So thank you so much and be well and have a wonderful day.

physician burnout

wellness strategies

radiologists

emotional exhaustion

personal resilience

systemic changes

micro habits

positive social connections

gratitude