The term microaggressions was first coined by Dr. Chester Pierce, who was a psychiatrist at Harvard University. He described racial microaggressions as everyday, subtle, stunning, often automatic and nonverbal exchanges which were used to put down black people by offenders, and that the offensive mechanisms used against blacks were often innocuous. In 2007, Dr. Daryl Wing Suh, who was a professor of psychology at Columbia University, expanded Dr. Pierce's definition of microaggressions from just racial groups to include individuals of all marginalized statuses in society, such as different religious faiths and the LGBTQ and differently abled communities. Dr. Suh also divided microaggressions into two different categories, microinsults and microinvalidations. Microinsults are the words and actions that make people feel inferior, othered, or abnormal, like they are not welcome in the space that you are in. And microinvalidations are the words and actions that invalidate the thoughts, feelings, and experiences of others. And I think we all probably have heard these and maybe have even been perpetrators of them when you say, you know, it was just a joke, you shouldn't take things as seriously, they didn't mean it that way. And I think that probably the worst one is I don't see color. When you say that to a person of color, that completely invalidates, I think, who they are. What microaggressions are not are the underhanded and subversive things that colleagues may say or do to you at work. These passive aggressive words and actions may also be extremely negative, but they are not microaggressions if they are not rooted in the fact that the person belongs to a marginalized group. We all know that overt racism and bigotry are illegal in the workplace, but they aren't gone. They just show up in the softer, nicer words and subtle actions stemming from our biases. And when they manifest themselves in the form of microaggressions, the fact is we all have biases. They are how we make sense of the world. And while they can be both good and bad, some of them are more harmful than others. All right, so we're going to try something. I want everyone to imagine a chicken. How many of you were able to produce this image in your mind? We have a very wide audience, right? And despite the diversity in this audience, I bet you all of us thought of this chicken. So even if you've never even seen a chicken in real life, this is probably the image that will come in your mind. So why is that? It's because it's the picture that every book, movie, cartoon, advertisement that you have seen, this is the chicken that is shown. So even if you know that there are a bunch of different chicken breeds, this is the image that will probably be the first one that pops in your head. So this is your bias, our biases. We weren't born knowing what a chicken looks like, but your bias now is what makes you think that this is the first image of a chicken. And so the biases come up because they are shaped by all of the influence and exposures that we have in our life and that we're not really paying attention to. So why am I talking about chickens? Because biases are biases. If the first image of a doctor or chair of a department you think of looks like this, it's because for the same reasons as for the chicken. You weren't born knowing what a chair looks like or what a doctor looks like, but this is probably what you think of because of every book, movie, and advertisement, etc., also shows you this image of what a doctor looks like and what a chair of a department looks like. And so when institutions place people in leadership positions such as chair, they're unconsciously looking for this gentleman and none of these individuals. No one is going to explicitly say or think that a Muslim female couldn't be chair, but she's also just not considered to be in that space because unconsciously she's not chair material. They're thinking about the other gentleman on the prior slide. There are lots of examples of microaggressions that people have probably heard in the past few years, but I wanted to share a few personal examples to highlight really how subtle microaggressions can be and how there really is no wokeness. I'm giving this lecture on microaggressions and still I'm the source of microaggressions all the time. And it's not about trying to become unbiased because that's literally impossible. It's more about becoming aware of our biases and then trying to be better with them and so have them not become microaggressions to other people. So let's say this group comes down for you for a consult. Who do you think is the attending or who do you think is leading this group and whom would you address? If I show the rest of the picture, you can see that the female in the corner is actually the attending with the long coat and actually the two males are medical students in the short coats. For me, I know that subconsciously and implicit my bias is favorable for men being in charge. This is not what I consciously think about. I'm a female physician. I know a lot of powerful women physician leaders. But I know that this is my implicit bias and it comes from a cultural and family upbringing and also something that has been constantly confirmed by society in the pictures and everything that we see. But I noticed that when people would come down as a group, I would notice that I would immediately just speak to one of the males in the group and address that person and not realizing that most of the time they were actually not the leader or the attending in that group. But I just automatically assumed that. So now when a group comes down and I actually don't know who the people are in the group, I make a really big conscious effort to speak to everybody in the group and particularly pay attention to the females. And it's surprising to me because it's really a deliberate effort that I have to make every time a group comes down to speak. Another example that has been coming up frequently because we're in the middle of residency recruitment season is that, you know, like you were so quiet, the Asian students are so quiet. You know, we have to think that just because being quiet is not celebrated in American culture does not mean that it is a negative trait. So we have to bring some cultural sensitivity to the table. I mean, if we had a Jehovah Witness patient, you wouldn't force them to give up their beliefs about blood products and make them take blood products. So we should give the same cultural sensitivity to our students and realize that being quiet in Asian culture is actually something that is more honored than being that, which is considered to be inappropriate. So sometimes, yes, these students are shy and you have to understand that they're also coming over a personal shyness, but also a cultural barrier of being very gregarious. And so we should not demand or expect that Asian students should be gregarious or be considered that they're not being engaged. This is a really good friend of mine who was an ENT surgeon at Georgetown before he left to become faculty at University of Pittsburgh. Now that I'm speaking in front of you, I'm going to mess it up, but Dr. Sean Schwiederhan. And you know, his name was really hard for me to remember and to say correctly. And so to be honest, I never bothered to learn how to say it. I would always call him Dr. Sean or Dr. S or Richard and try and kind of laugh it off. And it was, you know, because my name is Ann J. Right. I don't have the issue of people messing up my name. So it doesn't even occur to me that it might bother people about this. But it did. It was offensive to him and he called me out on it and I'm really glad that he did. But it's still, it's still my responsibility and it's still, you know, it doesn't excuse me from being, you know, in the wrong if I just didn't think about it. And yes, still female medical students or residents are being told that they have to choose between having children and having a career in a procedural specialty. So if you are speaking with a trainee and you're not, and you're talking to a male trainee and you're, if you're not going to ask them to choose between fatherhood and a career, then please do not do that to the female trainees as well. This is one I think that has been talked about for a really long time, but it's still very prevalent I think in academic medicine. You know, men are allowed to be assertive, direct and abrupt when they're in leadership. But when women do it, it's being, it's often taken as being so overly aggressive and borderline inappropriate if women are assertive like this. And I have to tell you that I have throughout, you know, my training and career, I have probably heard the meanest and most inappropriate things said about women who lead with assertion. Whereas men do not even remotely face this level of scrutiny, you know, in fact it's the opposite. They get a lot of admiration for their leaders, for their leadership if they're being assertive. You know, academic institutions, one of our main missions is teaching and training the next generation of physicians. However, teaching is really considered to be somewhere that, something that women do. And it can be done for free, while men should focus more on research and publishing which are regarded with much more academic clout, particularly when, you know, when they're going up for promotion. You know, and being able to teach and being able to teach well, it's a really, it takes a lot of time and it's a really hard learned skill. But for some reason it's not really valued as much I think in our academic institutions. This was an article that was published in AUR in 2016, which shows the percentage of women in leadership in academic radiology departments. So if you see, as the power and prestige of the position increases, the number of women start to decrease. So now imagine the percentage of people at these top positions, when you look at the intersections of groups like black women, the numbers are going to become almost non-existent. This is a little bit old. I see Dr. Cannon in the audience, and it's actually probably about 17% of female chairs now. But still, it's not, this level of attrition is, I mean, the level of women shrinking as the positions go up can't be related to attrition or the fact that women are leaving academic positions. It is not uncommon for women and people of color to feel like we have to work harder and better than everybody else. And that is because of multiple reasons, because we don't want to feel that anyone is ever going to question the reason why we got the position that we're in. And once we get there, we don't want to have the imposter syndrome. So we feel like we have to be overly qualified, overly qualified to be in that position. And so when the accumulation of microaggressions over a lifetime add up, the consequences are negative for both mental and physical health. So how do we do better? I think it's really incumbent on all of us to take up the responsibility to learn. There's an overwhelming amount of resources out there that can come in like small, digestible bites of information to large tomes and books, et cetera, which are much heavier. But you can start with like the 1619 podcast. It's a five-part series. Each session is about 20 to 30 minutes. And it's a wonderful, you know, it gives you a wonderful journey through the history of black Americans in our country. There's also multiple TED Talks, which last from five to, you know, 20 minutes that can give you also a lot of information, a lot of insight. And also reflect on how the threads of biases and microaggressions can be seen in your life. You know, it's not only white privilege that is on the table here. Our individual privileges are often really quiet and much harder for us to admit, to see. But if you think if we are aware of both our privileges and our biases, the pathway to change can appear. So I'm going to end with this microaggression triangle model, which was published in Academic Medicine in 2020. It's a really unique model that views microaggressions from a human interaction perspective. And it really involves all participants of microaggressions, the recipient, the source, and the bystander. And it gives actions for all of us to take so that we can start rebuilding relationships by each of us doing our part. So this model really emphasizes that you can't, you know, we can't change anybody else's thoughts and feelings. We can only change ours. And so we can't wait for someone else to change to make the situation better for ourselves. And so, you know, if I was going to wait forever for microaggressions or the sources of microaggressions to, you know, become aware of them and start, you know, doing these microaggressions, it's going to be a really long time. So what is it that I can do to make myself, you know, mentally and physically healthier about this? You know, building resilience, you know, finding a support group or support, you know, team, I think is really important. And also what institutions can do as part of the bystanders. And with that, thank you very much. And I'll be talking today on sexual harassment. While this talk focuses on the experience of women, I must acknowledge that it is critically important to consider the gender spectrum and intersectional identities such as race, ethnicity, sexual orientation, and disability when discussing sexual harassment. Individuals with intersectional identities may experience amplified adversity with harassment and discrimination, and they may experience it differently and more severely. The Equal Employment Opportunity Commission guidelines define sexual harassment as unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature when this conduct explicitly or implicitly affects an individual's employment, unreasonably interferes with an individual's work performance, or creates an intimidating, hostile, or offensive work environment. Gender-based harassment is a term designed to emphasize that harmful or illegal sexual harassment does not have to be about sexual activity. This figure from the National Academies of Science and Engineering and Medicine's 2018 publication on sexual harassment of women illustrates the relative relationship of sexual coercion and unwanted sexual attention with public consciousness. Gender-based harassment is by far the most common type of sexual harassment. However, as illustrated by this figure, the largest component, much like this glacier, occurs below the surface of public consciousness. Today, I will be primarily discussing sexual harassment, which usually resides above public consciousness. The line of public consciousness is affected by many things and is not stringent. Therefore, a distinction of sexual harassment and gender-based harassment may be challenging and this line blurred. Of course, it is the ultimate goal of panels, through panels such as this, that all sexual and gender-based harassment be recognized and not tolerated. Sexual harassment was first recognized in cases in which women lost their jobs because they rejected sexual overtures from their employers. Such coercive behavior was judged to constitute a violation of Title VII of the 1964 Civil Rights Act. Soon thereafter, it was recognized in employment law that pervasive sexist behavior from coworkers can create horrible conditions of employment, which became known as a hostile work environment. This hostile work environment also constitutes illegal discrimination. Sexual harassment first became codified in U.S. law as a result of a series of sexual harassment cases in the 1970s and 1980s, about 40 years ago. In radiology today, about 27% of residents are women, 21% of radiologists are women, and women constitute approximately 11% of radiology leaders. This is important because research has consistently shown that institutions that are male-dominated with men in positions that can directly influence the career options of women who are subordinate to them have higher rates of sexual harassment. About 40 years after workplace sexual harassment was determined to be employment discrimination and illegal, it is still pervasive in radiology. Further, the percentage of women reporting sexual harassment has increased over the past couple of decades. In 1998, research revealed that 26% of women in the field of radiology had endured unwanted sexual attention in their workplace, while 40% had encountered gender discrimination. Comparatively, in 2017, 24% of female radiologists disclosed workplace sexual harassment. A year later, 47% of practicing female radiologists revealed similar experiences of harassment while at work. Most recently, Peto et al. used an online anonymous questionnaire developed through the Association of University Radiologists Affiliated Task Force to assess participant experiences of gender discrimination and sexual harassment. A total of 375 female radiologists completed the survey, and in keeping with gender representation in radiology as a whole, most were from groups that had about 27% or fewer female radiologists. The majority of respondents, 60%, reported having been victims of sexual harassment, and 85% experienced gender discrimination in the workplace. The results of this survey must be emphasized. Forty years after workplace sexual harassment was determined to be employment discrimination and illegal, the majority of female radiologists report having been a victim of sexual harassment. The increase in the percentage of women radiologists reporting sexual harassment in 2021 may be in part related to the Me Too movement. Given the impact of the Me Too movement on women's willingness to identify as victims of sexual harassment, it is challenging to determine whether there has actually been an increase in sexual harassment in radiology over the past decades, or if more women are reporting their experiences. Of the women radiologists experiencing sexual harassment in the Peto study, most experienced unwanted verbal remarks, including unwelcome sexual advances, requests for sexual favors, and other verbal conducts of a sexual nature that interfered with their work performance or created an intimidating, hostile, or offensive work environment. Nearly half of the women who reported sexual harassment experienced unwanted touching of a sexual nature in the workplace. And while sexual coercion and rape are less common, they are unfortunately still present. Experiences of sexual harassment and gender discrimination are interlinked, and panels such as this one are an important step in lowering the threshold of public consciousness and creating zero tolerance for both. To this end, it is worth reminding everyone that we are not discussing historical behavior occurring in a poorly behaved fraternity. We're talking about behavior that's occurring in our radiology ranks, in our reading and procedure rooms. The Peto survey was one of the first to include and acknowledge that patients are frequent perpetrators of sexual harassment. And that in two-thirds of instances, the perpetrators were not seniors or superiors. Therefore, our strategies for sexual harassment mitigation must include improved protection strategies for women radiologists from perpetrators in these groups. Remembering that institutions that are male-dominated have high rates of sexual harassment, we must also consider the context in which sexual harassment in radiology is occurring. Radiologists report high levels of burnout, with only half of radiologists stating they are professionally fulfilled. Experiencing sexual harassment amplifies burnout, with increased burnout rates in victims and expected reduced job satisfaction. Significant gender differences in burnout, with women reporting higher levels, are known. However, the degree to which sexual harassment contributes to this increased burnout in women radiologists is not fully understood. Part of why we may not fully understand the impact of sexual harassment on burnout in women radiologists is because of the pervasive culture of silence. Eighty percent of women who experience sexual harassment or gender-based discrimination in the Peto study did not report the event. The reasons for not reporting were led by a fear of negative career impact, the power imbalance, and a fear of retaliation. Further, many women felt that reporting was futile. While understanding why women do not report sexual harassment and gender-based discrimination is important, it is much more important to recognize that the responsibility for addressing sexual harassment in radiology does not rest on the victims of sexual harassment. It is rather all of our responsibility. We must lower the line of public consciousness in radiology such that we are all aware and do not tolerate any gender-based harassment or sexual harassment. To accomplish this, we must first and foremost publicize anti-harassment policies and hold individuals accountable. We must send clear signals that reporting is not futile and that sexual harassment is not tolerated. We must develop policies and procedures that give targets of harassment options for reporting and protect them. We must give them greater control over how and when they proceed with their harassment case to protect them from intimidation and retaliation. This may include services such as a group or institution on modes. The two strategies I just relayed for culture change are imperative, but we also must address our under-representation of women in radiology and the paucity of women radiology leaders, recognizing that this has been shown to contribute to an increased likelihood of sexual harassment, that this paucity has been shown to contribute to an increased likelihood of sexual harassment, which it contributes to the increased burnout rate in women radiologists and then could potentially lead to women leaving the workforce. We in radiology also must strengthen our sexual harassment training and welcome sessions such as this, which remind us to be mindful and encourage us to be upstanders and not just complicit bystanders. He or she is also an important component of mitigating sexual harassment. Upstanding male radiologists, as the majority, have the greatest opportunity to affect change and their participation in this culture change is vital. I've previously spoken on gender-based harassment and at the time mistakenly thought that we were transitioning as a culture from more overt sexual harassment to the underwater component of the glacier. While preparing this talk, however, it became clear to me that these more egregious events happen more often than I realized and that the victims rarely report them. We in radiology must acknowledge their chronic toll and impact on radiology's burnout rates and gender representation. Further, it is the responsibility of all of us in radiology to change our culture to one of zero tolerance. Thank you for your attention and joining us for this important conversation. So I'm going to talk today about professionalism transgressions and what we can do about them. I want to start by saying that I hold no special wisdom here. You know, this is experiential knowledge and this is what I'm going to share with you today and try to put it in context of what we can do about workplace professionalism transgressions. So what kind of behaviors are we talking about? There's really an infinite number, but some of the most common include incivility, discrimination, non-team behavior, bullying, which we've all witnessed increasingly, harassment and sexual harassment and so on. So unfortunately this list is very incomplete, but we know it when we see it. Now when you look at the costs of poor behavior in the workplace, it's incredible. This is taken from a poll of 800 managers in 17 industries and you can see people decreasing their work effort, decreasing time spent at work, the quality of their work, lost time, lost work time, people saying their performance declined, their commitment to the organization declined, and 12% of people leaving their job because of incivil treatment and taking frustrations out on customers. This would be our patients. So the cost of this is very real and we need to think about this as we develop our workplaces. It has been said that 13% of managers and executives' times are spent dealing with incivility and think about the value of that time just being lost to something that should never happen in the first place. The question then becomes what can we do about it coming at it from a problem-solving perspective and I realize that when I talk about this, I'm coming from a place of privilege that is that and power. I'm the chair of my department and so I have, I think, a greater responsibility and those of us who are in this audience who are leaders have a greater responsibility. In many cases, people may not feel they have the power to talk about it. So I think a lot of us should be thinking about this as a starting point. And so with this, I start by saying that we should all heal ourselves first and all of us, I think it's impossible to get to adulthood without doing something that has hurt someone else. And I think that it's incredibly powerful when you cross a line yourself to say, I'm sorry and healing yourself first is, I think, the number one step that every single one of us can take. And those of us in leadership need to model the behavior we want to see. Now someone who may not be in a position of leadership or may perceive themselves not being in the position of leadership should think about this, that teams, the way that they work, I think are fluid. Leadership is fluid. Sometimes someone who's ostensibly a leader may find themselves being the least knowledgeable in a team of people and someone else may be leading it. In my own lab, I have often found that medical students in their projects are leading a discussion in that and then they're the leader and I'm the follower. And so I think this is a really important thing that whenever we're in a position where we're leading, we need to model the behavior we want to see. As people who do have power, I think we need to be thinking about hiring for decency first as the prerequisite criterion that we're selecting for. And in doing this, vetting and making a lot of phone calls that are painful, difficult, time consuming is really important because an ounce of prevention is a huge, huge, huge benefit to an organization. A flip side of this, and I think medicine suffers in this, is that people are not always honest when they're giving feedback about someone who may be, about whom they may be getting a call. Now, this is really important. We've encountered this in the news regarding, say, police officers, not wanting to talk about other police officers, but the same issue exists in medicine and we need to be able to say that, actually, you know what, there are some problems about this person that I want to discuss with you. And I think that that's a better thing for a phone call than an email, but it is something that needs to happen. Now, in any interaction with people, I think we need to be able to share our expectations of one another. That includes if we're not in power. If someone is acting inappropriately, we need to be able to create situations where people, even those who are not in power, can state that, hey, I'm not comfortable with what is happening here. That involves a culture change that takes a very long time. It's not something that may exist in all situations at all times, but I think that we need to be working towards this, otherwise we're in trouble. And I say this reserving oxygen for good behavior in a really heartfelt manner. Now, the problem is, I think, that what happens in our workplaces sometimes is that bad behavior, because it's bad, gets a lot of attention because we need to cure it. What it does is it takes away oxygen from the people who are behaving well, which is a majority of the people, and especially those who are quiet in our workplace. And this, I think, is one of the most harmful effects of bad behavior. And I think that reserving oxygen for good behavior and calling it out consistently over and over, and I'd like to say to my leadership team, at least, that we should be talking about the positives of our department all the time, because that's what we want to model. That's what we want to resonate with our people. And I think that talking about the positives is really important out there. And this is driven by evidence. So we, in our department, are partnering with the Center for Positive Organizations, CPO, it's called, at the Ross School of Business at the University of Michigan, and they examine top 1% of organizations around the world, and they have a rich body of data that actually show how positive interactions drive excellence. And this is driven by recognizing and fostering collective strengths, resources, potential. So they emphasize high-quality connections, short-term interactions that involve respect, reciprocity, trust, and these can be very brief exchanges. And they improve workplace performance by increasing cognitive skills, creativity, positive emotions, positive connections. So this is a body of research that is developing that I think is worth looking into. And I'm benefiting from having someone from the PBO in our department embedded. We pay for part of her time to be as part of our department. And this even improves physical health. It's kind of crazy that this kind of thing would have an impact on the physical health of your department. But what if someone is behaving badly? What do we do about that? And the first step in that is not to do this, right? And we, you know, I'm joking, and this is tongue-in-cheek, but this is also very real. This is what happens in real life. And the kind of things that you might hear, I mean, they may not be an exact quote, but they're horrible in setting X, but they're an excellent clinician. They really care about their patients. This is why they're acting this way. They do it because they expect perfection. They're an excellent researcher, you know? They bring in billables or research dollars, right? They work incredibly hard. They're super fun in other settings. And I will point out that almost no one who does these things is bad all across the board. Everyone is operating in a gray scale. So all these things exist out there. They only do it when they're stressed, and of course, medicine is a stressful occupation. So do they do it all the time then, or, you know, how does this work? And they were mostly joking around, right? And so these are huge problems, and I could go on with these kinds of quotes, and we cannot excuse that. We have to correct it when we encounter it. A second part of this is that we either stand for something or we stand for nothing. And this is something that has been pointed out to me by Dr. Diana Gomez-Hassan, who is one of our associate chairs, and, you know, she has been a big advocate for drawing a line in the sand. When things go too far, we should not tolerate them. Fostering nontraditional models of leadership is another part of this, because I think that sometimes we only welcome sort of an aggressive approach to leadership. And when we stop doing that, I think it will stop some of the bad behavior that we see. Now, when we are talking to people, I think we need to be able to titrate responses. One of the programs that's been adopted at our organization is the Vanderbilt Program for Patient Advocacy Response System, which is PARS, and Coworker Observation Reporting System, which is CORS. And this takes reports of bad behavior and then turns them into actionable items that you can go and talk to people with and titrate a response. And one of the concepts from this is early intervention, and you can have trained intervention, i.e. people who are trained to go talk to people in workplace transgressions. And the first step of these is a simple cup of coffee conversation where people go and talk to somebody and say, hey, wait a minute, this was a problem. And as much as 83% of people end at that point, they don't go on to further problems within the PARS CORS system. So early intervention and proper intervention really prevents a lot of future problems. One of the things that I stress is getting individuals to partner in their improvement. If you point out to someone, hey, you're doing this or that bad, or you point out to someone, hey, how do you think this made someone else feel? They may themselves come around to saying something, hey, you know, I think I can improve in this. So I think getting them to partner in their own improvement is a really important thing. And this, I'm speaking directly to people in power in this audience, annual reviews are a huge opportunity for improvement. When we give annual reviews, they can be rubber stamps, hey, you're renewed to next year, you're doing great. Or we can actually talk about some of the problems that we run into. On the flip side, if you're receiving an annual review, please receive it in a manner that is receptive to change. Proper note-taking so that you're documenting the problems that are happening that may be needed in the future. Bystander training is something that has helped me a lot because each of us runs into problems where you run into issues that you've run into where I wish I had said X, I wish I had done Y, and you don't. And I think that even thinking about this and rehearsing what might happen the next time is really important. Dr. Marie Lozon is a Chief of Staff at University of Michigan Health Systems, and she said this to me on the first day I chatted to her, that non-renewals are a tool that chairs do not use often enough. And I think this is something that I have taken in my mind, this is a tool that exists for us. With this, I want to stop and thank two people who've helped me incredibly in culture issues. Dr. Amy Young, she's a professor at the Ross School of Business and the Center for Positive Organizations and spends 20% of her time with the Department of Radiology. And Dr. Kim Garber, Dr. Amy Young and Dr. Kim Garber, Dr. Kim Garber is the Associate Chair for Department Life and Culture and has really helped me set a tone that I want to for the department. With this, I thank you for your time. Great. Thank you for that introduction, and I'm glad to see all of your faces here today. So let's start with a scenario here. I'm sure all of you in this room can recognize this resident, 7 o'clock in the morning after a busy overnight shift, waiting for their faculty to come staff them out. It is now 8-7-50, this resident has waited 50 extra minutes after their long overnight shift. They are delirious and still their faculty hasn't arrived. Finally, the faculty busts into the room, is ready to get started, and the resident can tell that it might be a rough morning. Only a few minutes later, the resident is now being berated for missing these thyroid nodules on the 17th trauma pan scan that they saw in the last three hours of their overnight shift. And the other radiologists start to filter into the room at 8 o'clock while the staff out is ongoing. And things get worse when the faculty is screaming, you're wrong again, you make things so difficult. And we can see that everyone in the room is feeling a little bit uncomfortable. The program director shows up for their shift, well rested and happy. And the observers in the room walk into the program director's office and share that they've witnessed a difficult situation with a trainee in the morning. The moon changes rapidly and we all wonder, how is this conversation between the program director and the other faculty going to go? So let's take a moment to think about how we might approach this situation, whether we are in a leadership role, whether this is a peer that we are witnessing this in. So the first thing that we need to do is really assess the scene and determine if there are immediate safety issues. And first off, we'll want to determine if there is a possibility of self-harm from the transgressor. So how can we recognize suicidal ideation or someone who might be at risk for suicidal ideation? These are a few of the comments that you might hear this person saying. I feel like I'm a burden to others. I feel hopeless. I feel like I'm trapped in my situation. And most explicitly, I have no reason to live. So these are things that should tip you off to the possibility of self-harm. Behaviors that someone who is experiencing suicidal ideation may exhibit are increased use of alcohol or drugs. They may withdraw from social activities and isolate themselves from others. They may sleep more than usual or too little. They may begin calling people and visiting to say their goodbyes, and they may begin giving away prized possessions. People who experience suicidal ideation may exhibit depression, anxiety, irritability, a sense of humiliation, agitation or anger. And in sort of a turn of events, they may experience relief or sudden improvement if they are thinking of acting on their ideations. So if you suspect that there is a chance of self-harm, please take a picture of this slide. These are resources that you can provide to the person. There are hotline phone numbers from the American Suicide Prevention Society. You can also text TALK to 741741 to have an immediate conversation with a counselor. So beyond self-harm, we need to assess for a possibility of harm to others. And if you perceive that there is a possibility of harm to others, then we'll get on the phone and call for reinforcements. So of course, these are going to be the extreme instances when we do suspect that there is danger to self or others. So more commonly, we're going to say no in this situation. So what do we do now? We know someone is being disruptive in the workplace because of depression, because of burnout. What do we do next? So we may look for signs of burnout. People who are burnt out exhibit exhaustion. It may be physical exhaustion. It may be emotional exhaustion. They may begin to depersonalize things. They may become very cynical or sarcastic, have a very short temper, may begin berating overnight residents about their misses of thyroid nodules on the trauma polyscan. These people may have a lack of efficiency and question the meaning of their work and question the quality of their work. So we talk a lot about how many of us are burned out, but we talk less about how we can recognize burnout in others. And these are some of the features that we can look for. What are some of the consequences of burnout that we can see in the workplace? Well, burnout has been associated with lower quality teamwork. A survey of nurses and physicians in ICUs in Sweden showed that emotional exhaustion predicted the deterioration of the quality of their interpersonal teamwork and that emotional exhaustion predicted decreased clinician-rated patient safety. Burnout can lead to increased absenteeism. It can lead to people showing up late to work, like 50 minutes late to their ED staff out session. It can lead to an increased intention to leave their current job, increased intention to leave medicine altogether, and may have a lower day-to-day work productivity. People who are burned out have a 25% increased odds of alcohol abuse and dependence, and this increases to 50% in the setting of depression. And it can increase the risk of suicidal ideation by almost three times in residents and to twice as often in faculty members. So there are real consequences of burnout that we can see in our day-to-day work. I'll take a moment to talk about the scope of the problem. This is not terribly hard science, but this is the survey that Medscape does every year. It gives us a sense of who is experiencing what across the fields of medicine. In radiology, we may not rank the highest in how many of us experience burnout, but still, I would argue that almost 40% of radiologists experiencing burnout is a huge number. So we are apt to encounter disruptions in our day-to-day work as a result of symptoms of burnout. As for suicidal ideation, again, we may not rank at the top of the list, but 12% of radiologists do endorse suicidal ideation. And when we look at these numbers a little bit more closely, we see that there are 6% of respondents from this survey who chose not to answer. So, in fact, there may be nearly one in five of us who experience sensations of suicidal ideation. And this graphic here shows that nearly 50% of people who have suicidal ideation don't tell anyone about their thoughts. So this is something that people aren't going to be explicit about, but that we may have to appreciate from their implied behaviors. So let's go back to our program director, who is having to have a conversation with Dr. Ray about their behavior in the reading room. So what can we do? So I think that the most important thing to start with is asking and listening. Really just, hey, what did you think happened, what happened this morning, and why do you think that is? This is a quick read, this book by Michael Sorensen, I Hear You, and it's a great book and a great resource on how we can actively listen. The breakdown of the book, here on one slide, four bullet points, is to first listen without judgment. So take your judgment and leave it outside the room when you're having a difficult conversation like this. Listen with empathy. Validate the experiences and the emotions of the person. You don't have to agree, but you can at least validate and say, I can understand why you might feel this way. And then ask how you can help and let them know that you are there for them. I would encourage you to offer your personal advice only if the person is receptive to it or has asked for advice. Otherwise, listen without judgment, listen with empathy, and provide the person with resources that they may need. You may want to employ a coaching approach. Here is another resource, this book by Robert Hicks, who discusses coaching in the setting of medical professionals and teaches you how to really help a person come to their own conclusions on things without telling them what to do. Here are some examples of coaching questions that you might use in this conversation to help the person help themselves. It's really important for you to know what your local resources are, what you have available to you. A Medscape survey reveals that only 35% of respondents say that they have programs to reduce stress and or burnout. And the majority of people say no or don't know. And I would argue that the answer really ought to be yes in the majority of instances. And I really think that people just don't know what's available to them. So you can do this today, check to see what's available at your own institution, what's available for faculty, residents, and staff, and what resources are available to help you as a leader. This is an example of all of the resources that we have at our institution. I serve on the Provider Wellbeing Committee for our institution and have for years. And when this graphic came out a couple weeks ago, I was unaware of all of these resources. So even as someone who is in a leadership position from a wellbeing perspective, I still really didn't know everything that the institution had to offer. I'm certain that almost all institutions will have an employee assistance program. This is a voluntary program. It is almost always free to anyone who is employed. It offers counseling programs and many employee assistance programs will offer assistance in realms other than just mental wellbeing. Here's some examples of what our resources look like, and to show that the resources include the resources other than mental health resources. And finally, I would encourage you to check in with this person. Check in often. The check-ins can be brief, just a quick, hey, how are you doing? They can be more formal, but checking in to make sure that the person that you're concerned about is doing okay and has the resources that they need is super important. So here is a flow chart for disruptive behaviors due to mental health concerns. Remember to check for safety concerns. If there's not an imminent safety concern, we're going to listen. We're going to always check in with our people and we'll know our local resources. So assess the scene. Is there danger to self or others? Know your resources and have a plan. And I thank you so much for your attention.

workplace challenges

microaggressions

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leadership diversity

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organizational culture

burnout prevention

inclusive workplace