Physician Fundamentals

JILLIAN HORTON: Hello and welcome. I'm Dr. Jillian Horton, a general internist at the University of Manitoba. And today we are going to spend time talking about strategies for finding our meaning and purpose in our medical work. 

Before we get started, I want to begin with a land acknowledgment. The University of Manitoba is located on Treaty One territory, which is the ancestral land of the Anishinaabeg, Cree, Oji-Cree, Dakota, and Dene peoples, as well as the traditional homeland of the Metis first nation. 

And when I do a land acknowledgment, this is an opportunity for me to reflect on the relationship between colonization and its long legacy in terms of the clinical problems that I, as an internist, treat every single day and an opportunity for me to move deeper in my own reflections on the relationships between those two things and reflect as well on what opportunities I can continue to engage with personally with reconciliation. I have no relevant conflicts to declare. 

So in terms of my objectives for our time together today, I have four of them. So my first hope is that after this session, you will be able to describe the relationship between meaning in work and burnout. My second objective for this session is that it will give you an opportunity to assess your professional activities and the alignment between both your personal values and your purpose. 

Thirdly, I hope after this session, you will be able to explain the evidence related to crafting 20% of your time to minimize the risk of burnout. And finally, it's my hope that when this session is done, you'll be able to better identify some of your beliefs and the ones that might be limiting your ability to reprioritize activities that best connect to your personal sense of meaning and purpose. 

I want to invite you to reflect on a couple of simple questions right now. And the first question I want to ask you to think about is, what is your perfect workday? What does that workday look like? What elements does it consistently have? What does that day look like for you? That's reflection number one. 

The second question I want to invite you to think about is, what percentage of the components of that perfect workday are actually within your control? So if you look again at that imaginary perfect day, the things that happen on that day, which ones are within your personal locus of control? 

As you sit with your answers to those two reflective questions, I want to invite you to think about three specific paradigms for work and these paradigms that we do not necessarily delineate with consistency when it comes to our identities as medical professionals. 

So when we think of our work, we can begin by thinking of work as a job. When we think of work in that perspective, we're thinking about the focus being on a financial outcome, a means to an end, a way to support ourselves and support the things that we need, our material and physical needs in order to live. It's not really a net positive when we conceive of work in this model as a job. 

The second paradigm that we can use is thinking about our work as a career. And when we consider work as a career, typically, that is not a plateau. We think of it as having a trajectory that sees us advancing. We move forward and forward. We become more senior and ascend progressively to roles with more control, more seniority, perhaps more influence. 

But there's a third model of work that we can reflect on. And that third model is work as a calling. And when we think of work in this way, the focus becomes on whether our work is fulfilling and particularly whether our work is socially useful and serves a purpose. 

Now, before you settle on one particular paradigm that reflects your relationship to work, I want to introduce you to the concept, if you're not familiar with it, of medical exceptionalism. Now, historians point out that medical exceptionalism traces back for as far as we can go in the history of medicine. 

And, in fact, this quote is from a presentation in the late 1800s talking to a graduating class, a professor saying to that class that no other profession is essentially as special as medicine is. No other profession demands as much self-negation, as much sacrifice. This kind of language has been part of our professional identity for almost as far back as the records go. 

And, in fact, medical historians point out that medical exceptionalism is the idea that somehow not only is our calling particularly special and not only are the requirements of that calling physically, emotionally, intellectually, and spiritually particularly special, but it goes along with the idea that there is something incredibly physiologically special about us. 

And this idea is, of course, just a construct. It's not reality-based. But we experience it everywhere in medical culture. And sometimes it seeps into our self-concepts, our perceptions of our career, our work, our calling and can influence us in unintended ways. 

Now, I want to talk for a moment about some of our traits, traits that are characteristic to us as physicians, and this idea of our job as a calling. There is a body of literature looking at the physician personality and a couple of interesting papers to point you towards. 

In 1985, Gabbard published a paper called The Role of Compulsiveness in the Normal Physician. And Gabbard talked about some of the things that are initially adaptive for us, traits that make us thorough, make us detail-oriented, our commitment to patients, our tremendous desire to stay as up-to-date as possible on literature in our field of specialty. 

But Gilbert also pointed out that those traits can quickly move from adaptive and being helpful to patient care to maladaptive. So diagnostic rigor can also lead to, for example, difficulty letting go. Being thorough can mean that we have trouble setting appropriate limits or giving ourselves the ability to stop thinking about cases or mistakes that we've made. 

Our commitment to patients can lead to an exaggerated sense of responsibility. And our desire to stay up to date can actually become maladaptive when it is riddled with anxiety, a sense that we are always behind, which actually is reflective of the reality of the volume of information that we are assaulted with every single day in our medical specialties. 

Lemaire and colleagues have also looked at aspects of the physician personality and how we identify with certain characteristics, such as describing ourselves as workaholics or being control freaks or type A or type A-plus as I have heard it described elsewhere. And when you look at Lemaire's construct, you can see that many of us identify with one of these descriptors, many of us identify with two, and a large cohort of physicians identify with actually all three characteristics as being central to their personalities. 

There is a concept that I think is very helpful in the physician wellness literature, and that concept is known as self-valuation. Now, I often think of self-valuation as being a reflection of how willingly we will put other people's needs first on a consistent basis even when perhaps it is not absolutely necessary for us to do so. And some of these things, I think, for many of us can become habitual, things that we just do without actually thinking on a day-to-day basis. 

So some of the questions that we can answer that can give us insight into our own score when it comes to self-valuation are things like, when I make mistakes, I experience more self-condemnation than encouragement, or I am less compassionate with myself than with others, or taking care of my own needs seems incompatible with taking care of the needs of my patients. 

And we know that the lower our self-valuation scores, the higher our risk of burnout. And indeed I do believe that when we experience the sequelae of chronically-low self-valuation, one of the things that happens is, our sense of meaning and purpose and satisfaction in our work can also become threatened after a long period of time living this way. 

Now, there's definitely evidence that doctors struggle to integrate our professional and personal lives. And one of the things that this results in is a feeling of deep and private conflict about the relationship between our work, our job, our career, or our calling and our relationship to the work that we undertake with a sense of great purpose for the most part and high aspirations. 

Dr. Tait Shanafelt, who is one of the leading experts in the world on physician health, well-being, and burnout, talks about in one of his early papers that some of the characteristics that are common among us as physicians are a survival attitude, especially during residency. We have a sense that we'll just do whatever it takes to get through the experience. 

Also, delayed gratification. We enter into medicine with a sense that we're following a blueprint that is laid out before us. And at the end of a great deal of challenge and suffering, we will experience a particular outcome. So we are people who are very good at delaying gratification. 

And finally, we equate well-being with escape. We think of well-being as something that we'll achieve on a vacation or that we have to leave our clinical environments for. And this, of course, is not reality-based and does not help us to achieve fulfillment at work. Even though vacations and rest are important, this is not a strategy for organizations or individuals to achieve well-being in their work environments to think of escape as the only thing that they can do. 

So I want to invite you to think for yourself and to notice what arises for you when you personally reflect on the question of whether your work is a job, a career, or a calling. So you may have a private answer to that question that you would not necessarily be comfortable sharing with other people. 

And if you notice that that's the case, I want to invite you to ask yourself the question, can more than one thing be true at once? So it may be for all of us that some days at work, some of what we're doing just feels like a job. It just feels like a means to an end. And other days, what we're doing feels concordant with that sense of calling. And then there are other aspects of what we do that, again, mirror that career paradigm. 

So introducing the idea that more than one thing can be true for all of us, we don't have to ascribe to one paradigm. There may be elements of each paradigm of our relationship to work that feel true. That's normal and quite common for us to sense that the answer to that question might be a little bit dynamic. 

I want to shift now to talking for a few minutes about meaning and purpose in our work as being a key ingredient to our professional fulfillment. The Stanford WellMD Professional Fulfillment Model is a wonderful framework for us to internalize. 

It's my belief that it helps us begin to conceive of not only our own well-being and professional fulfillment but how we can begin to move forward in our roles as leaders, as physicians who are part of professional groups and clinic groups and a number of individual cohorts to think about how we can improve professional fulfillment on a number of fronts. 

But the Stanford WellMD Professional Fulfillment Model tells us that in order to experience professional fulfillment, we need three things. So the first thing we need is a culture of wellness. And a culture of wellness includes leadership that is responsive to our needs, leadership that is emotionally intelligent. 

It also includes equity-diversity inclusion and a sense of belonging, a sense of esprit de corps with the people that we work with, flexibility in our work hours and our work arrangements that reflects the complexity of our personal lives now more so than ever. 

The second thing that we need in order to experience professional fulfillment is efficiency of practice. So how much time in our work is wasted repeating tasks that would be better done by other people? Searching for bags, working across multiple electronic medical record platforms, doing the same task over and over that really does not affect the quality of patient care or relate directly to our expertise caring for patients. 

How much cognitive load do we carry that could be mitigated through external organizational measures? It's very hard for us to experience professional fulfillment if efficiency of practice is very low in our practice environments. 

And the third thing that we require for professional fulfillment is personal resilience. And personal resilience is about 10% to 20% of the overall factors related to how professionally fulfilled we are. And when we look at the problem of physician burnout, again, we know that it's not an issue with you not being resilient enough or me being not resilient enough. That, again, is only 10% to 20% of the overall problem. 

The primary drivers are organizational, cultural, efficiency of practice, processes related to our organization. But personal resilience is the piece that relates to our own physical fitness, our own cognitive fitness, our own sense of the social fabric that we have supporting us outside of medicine, the robustness of those social networks, how well we tend to our physical health, our sleep, our diets, our exercise when we have the opportunity to exert influence over those things. 

But the point I really want to make here is that in order to experience professional fulfillment, we need all of those three things. We can't just have one. If one domain is really poor in our life, then it's like a loaf of bread. We're missing an ingredient, and we will struggle to experience professional fulfillment in our lives. 

Another concept I want to introduce you to along those same lines is what's sometimes called the Shanafelt honeycomb matrix model. So this is the idea of looking at burnout versus engagement. 

And in Shanafelt's model, we see that meaning in work is supported by a number of other drivers, our sense of work-life integration, our ability to exert control and flexibility, our workload, our job demands, efficiency in terms of resources and resource allocation, the values of our organization and whether they're aligned with us, and what kind of community we have both outside of work and inside. 

And we can see that when these drivers are not supporting our sense of meaning in work that we're more likely to move towards the left side of the model to experience exhaustion, cynicism, and a sense of being inefficient and inefficiency at work versus when everything is in alignment and those drivers are supporting and helping us to develop our sense of meaning at work that we experience engagement and vigor, dedication, and we feel absorbed in the work that we are doing. 

Now, finding our work meaningful actually affords us a kind of psychological PPE. One of my favorite books on resilience is by the psychiatrists, Southwick and Charney. And one of the things that they emphasize in their book Resilience, which is highly worth a read if you're looking to learn more about the subject, is that having a sense of clear purpose dramatically strengthens our resilience. 

So this is one thing that we can continue to do on our own, one thing that is within the locus of control that we do have. We can continue to try to make our sense of connection to our meaning and purpose as strong and as clear to us as possible. 

Now, an interesting and widely cited study done in 2009 by Shanafelt and colleagues looked at, in an academic setting, what work clinicians were likely to say that they found the most personally meaningful. And when you look at a summary of the responses, the majority of respondents said clinical care was the work that they found the most meaningful. 

A smaller percentage identified research, education, and then the smallest percentage as administrative work, or an even smaller percentage identified other work as being their most personally meaningful. 

So this leads us to an interesting question. And that question is, is more better? Are you actually better positioned if you find a higher percentage of your work meaningful compared to a colleague who does not have such a high percentage of meaningful work when they look at what they do in a given week of their clinical lives? And the answer might surprise you. It originally surprised me. 

The answer is that there seems to be a magic number after which there is not much benefit to you finding yourself doing your most meaningful work, and that number is 20%. So to put that another way, after 20%, there does not seem to be any additional benefit when it comes to the relationship between doing your most meaningful work and decreasing your risk of burnout. 

So here's the next question. Is less worse? So there are some factors that are independently associated with a greater risk of burnout. And this also comes from Shanafelt's 2009 study. 

So the first factor is poor career fit. If you are devoting less than 20% of your effort to the activity that you find the most meaningful-- and, again, this applies to academic clinicians, but we can probably feel safe generally extrapolating this number-- then you are at an increased risk of burnout. You have what Shanafelt and West describe as a poor career fit. 

The second risk factor independently associated with a greater risk of burnout in this study was an age under 55. And most of us can say this actually makes sense because this is probably when we are doing some of the heaviest lifting for those of us with families when it comes to young families, child care responsibilities, and struggling to balance all those other aspects of our lives. 

Or perhaps we just learn skills as we age that make it easier for us to deal with stresses associated with burnout. And also, as we acquire more seniority, we mostly also acquire a bit more choice over what we can do. 

Thirdly, hours worked, total hours worked. The more hours you work, and, in particular, in other sources of literature, working more than 60 hours a week is associated with an increased risk of burnout. But total hours worked is a risk factor. 

And finally, from this work, being a generalist is a risk factor associated with a greater risk of burnout. To me, personally, as a general internist, this makes sense. There is an almost unlimited sense of the things that I feel that I need to keep up with in order to practice as a general internist in an academic center. So intuitively, for me, that resonates with me as something that feels true. 

So what is the low-hanging fruit here? Well, the message that I really take away and actually find incredibly comforting from this study is that physicians who spend at least 20% of their time in the aspect of work that they find the most personally meaningful had a burnout rate that was roughly half of that than the people who spent less than 20% of their overall effort in the work that they found the most meaningful. 

So I want to shift now to the question of how we get to that 20%. And I do want to say that even though those of us who are practicing physicians do have most likely some increased ability to influence our choices and what our work looks like-- we do have more capacity probably for negotiating those things and exerting choice. 

I do want to say that I think there are lessons here that apply even to residents as they begin to look at what their most meaningful work is and how they can choose to prioritize the things that they find the most meaningful even in the course of their very busy workdays. 

So here, I want to invite you to take a moment to think about your typical workweek. And so if you have more than one type of workweek as many of us do-- a week on a consulate service, then a week on an inpatient service, then a week covering outpatients, maybe you travel to a different location altogether to provide service-- you want to think about each of those types of weeks or settings that you work in separately and ask yourself the same question about each of them. 

So what I want to invite you to do-- and if you'd like to do this now, you can just hit pause while you do it-- take a pen and paper and see if you can create a pie chart for each one of your work types or workweeks to work environments that's similar to this type of visual model and that allows you to look and see what your work distribution looks like. 

And what you might end up doing is creating new categories for each of the types of work that aligns with your own job. And so you create a personalized pie chart. So, for example, if you were a person who does a number of procedures in one particular role or work type or workweek that you do, you might find yourself describing or breaking down those types of procedures within the pie chart that you create that represents your work. 

So just take a moment now to create the pie chart that represents the types of work that you do and thinking now about the percentage of time that you spend doing all of that work. Now if you like, I want to invite you to ask yourself the question looking at your different types of workweeks within the different settings in which you work. I want to invite you to ask yourself which activities are the most meaningful and which activities are the least meaningful. 

So from the different categories that you created on each pie graph, ranking them from most meaningful to least meaningful and doing that for each one of the pie graphs that you've created. Now, here's the helpful question. I want to invite you to consider that percentage of time as it relates to meaning. 

So when you look at all your work settings, what percentage of your time are you spending on the work that you find the most personally meaningful? And what percentage are you spending on the time that you find the least meaningful? Now I want to invite you to consider the percentage of time as it relates to meaning. 

So what percentage of your overall time-- looking at all of those pie graphs, those work settings together, what percentage of your overall time are you spending doing the work that you find the most meaningful? And then when you look at those pie graphs again, what percentage of time are you spending doing the work that you find the least meaningful? 

So now that you are looking at this worksheet that you created in front of you, you're probably wondering, well, what on Earth do I do with this data? And that's what we're going to talk about. 

There is a concept in the world of organizational and behavioral psychology called job crafting. So job crafting embodies a few key concepts. And one is the idea that we can take proactive steps that allow us to redesign what we do is essentially changing both our tasks and our relationship to those tasks and our perceptions of our jobs as a result. 

And another component of job crafting is, it gives us the sense that instead of our jobs being inflexible in things that we simply have to conform to, reframing our jobs as being tasks and interpersonal relationships that are independent building blocks that are flexible, that can be rearranged, reorganized, restructured, and reframed so that we can construct a customized job. And maybe that's the point for all of us where our job moves from being a job to a calling and ideally allows us to have more of a sense of meaning and purpose. 

So one concept that's embedded in job crafting is the idea of task perception. And this concept was really nicely illustrated to me once by Dr. Chris Sinsky who is the vice president of professional satisfaction at the American Medical Association. Dr. Sinsky talked about the fact that one day she was on her way to see her umpteenth consult in the emergency department. She was tired. She'd had an incredibly busy day. 

And instead of thinking to herself, I'm going to the emergency department to do another consult, she consciously decided and said to herself quietly, I'm going to the emergency department to help a patient. I'm going to have a meaningful encounter with a person who is never going to forget me. That's what is encompassed when we engage with task perception. 

So we try to reframe, for example, is the person laying bricks? Are they simply laying bricks and doing menial labor, or are they building a bridge that will be used by generations? So when you plow snow, the person who's plowing snow-- I live in Winnipeg, so that's a frequent occurrence-- is that person simply plowing snow doing menial labor, or are they clearing a path so that an ambulance can get a sick child to the hospital and save their life? 

And on a more granular level related to our work, are you seeing a consult? Are you doing what Dr. Sinsky was, simply seeing a patient? Or are you alleviating human suffering? Are you being given the opportunity to forge a deep and lasting connection with a person no matter how fleeting something that will impact them forever? So task perception is something that can be very helpful to us when it comes to the concept of job crafting. 

We can also begin to think about the concept of tailoring our relationship circles. So this invites us to ask the question, can we change the ratio of whom we interact with and how we interact with them in a way that best aligns with our meaning and purpose? So we might find that we get incredible satisfaction providing team-based care, working closely with our colleagues and allied health. 

We might have other colleagues who do not experience that same satisfaction and prefer to work a little bit more in isolation caring directly for patients without the support of any other team members. We can all begin to identify those individual characteristics. And we can actually, with some effort, tailor our relationship circles accordingly in certain environments. 

We might also find that we are people who really enjoy long conversations with patients. And other people are a bit less communicative and do not enjoy or are not as skilled in that realm. And so we may find that for those individuals, outsourcing some of that communication, getting the support of someone who is a very strong communicator in allied health, or having colleagues take some of the more relational tasks related to our work, colleagues who find that is where they derive their meaning and purpose. 

This is an example in our work environments of how we can actually tailor our relationship circles so we are all more likely to be able to spend more time doing the work that we find the most meaningful and purposeful. 

Now, I want to invite you to ask yourself a question. And that question is, what feels challenging to you when you reflect on this concept of job crafting and the idea of getting to that 20%? So some questions we can ask ourselves. Are there any assumptions we make about our ability to get to 20 that might not be true? 

Have we decided already that somebody will say no to a request we might have in our work environment or a colleague might not want to change the way that they distribute work? Might our assumptions be false? Are there other barriers? 

Are there uncomfortable truths, i.e., fixed beliefs about things that we must do, an income that we must make independent of our actual financial needs and our family circumstances, but the idea that somehow we're a failure if we don't make as much money as other people even if it allows us to do more meaningful work? 

And are there personality influences or personal influences, family members or mentors or colleagues whose opinions we value that we sometimes make choices based on the influence of those things without really taking into consideration that it's other people's perception of our work that's influencing our choices? 

So sometimes those challenges, we really have to be willing to look at what our own beliefs, biases, perceptions, and things that we've decided will not be possible for us. Sometimes we can challenge what those assumptions are and look at, in fact, our limiting beliefs. 

So here, in my experience, are some common limiting beliefs that prevent people, especially in the early stages of their careers, from getting to that 20% of the work that they personally find the most meaningful. So the first thing is, they think it won't matter. It won't help. My job is so hard. I'm already leaning towards experiencing burnout. Getting to 20% won't help me. 

And the reason I call that a limiting belief is, we don't know that that's true until we've tried. There is evidence that suggest that this formula gives us some immunity against burnout. So challenging yourself asking is the reason I think that this won't matter because I'm experiencing the cynicism that is often one of the cardinal symptoms of burnout. 

The second limiting belief is, people often think to themselves, well, the things that I find the most meaningful are not well compensated, and therefore, this isn't going to be possible. I can tell you from my own career journey that early on in my professional life, things that gave me a lot of meaning were not compensated at all. But I began laying the groundwork for developing expertise doing them. 

A wise colleague of mine, Dr. Ron Epstein, once told me that when we want to do non-traditional work, sometimes at the beginning of our career, we have to give it away. We have to essentially do proof-of-concept work to show that the things that we want to do are viable, that there is an interest in them, that we do have the skill to do them. 

So sometimes it's true that that work is not compensated at the beginning of our career. However, when we are strategic with good mentorship and a long game, we actually can create pathways where that work is not only minimally compensated but well compensated. 

And the third thing people say, well, my boss won't take this seriously. Nobody cares what I think. I can go and ask for this, and nobody's going to be interested. I obviously don't know your boss. 

But I can tell you that emotionally-intelligent leaders, especially when we can present evidence-- when we can go to them and say, you know what, here's this literature that shows that I should be doing 20% of my work doing what I find the most meaningful in order to reduce my risk of burnout by half, I'm not doing that right now. Here's the way I could get up to 20. 

My experience is that when we arm ourselves with literature in particular because we speak in evidence as physicians, with environments that are progressive, bosses that are emotionally intelligent and understand the crisis of burnout that we face, people may listen. So not assuming from a place of cynicism that people will disregard this when we go with a plan that is strategic and we've thought out our case. 

And finally, a limiting belief is often we say, my peers don't share my values. No one cares about patient-centered care the way I do or spending time with families the way I do. Now, in your work environment, that may absolutely be true. But, again, sometimes we tend to make assumptions and overstate the degree to which we are different from other people. 

And if this limiting belief is true, then that can sometimes be an indicator for us that we are in an environment where we are actually poorly matched. And if you think back to that model I showed you earlier, the Professional Fulfillment Model and the culture of wellness, this traces to esprit de corps. 

And if we have a sense that our peers do not share our values, that we don't belong where we are, then often that's actually a sign for us that perhaps what we have to look at is whether we need to move to a different environment. And sometimes that is the outcome of this type of work, this type of exercise. We realize, actually, I've done everything I can. I am not a fit. And I need to go and find my environment and my people. 

Now, you might think this all feels futile. And I know what that's like. I've been there too. I have experienced years of extreme professional burnout. And I've worked hard to job-craft and get myself to a different situation that eventually did have a significant impact on my burnout and my sense of meaning and purpose in my work. 

But what I really want to emphasize to you is, you don't necessarily need to know exactly what you have to do today. But as my friend and colleague Ron Epstein says, it's critical that we do something. We don't need to understand exactly what we have to do to have the perfect solution before we try to begin to address the problem. 

Trying one thing, then trying another, altering based on your early reflections on what work gives you the most meaning and purpose. This is at least a way to begin, a way to restore for all of us some kind of sense of a locus of control in our work. So we can't wait for a perfect understanding or knowing exactly what we must do, but we have to do something. 

And that's what I'd really invite you to think about in terms of the content that we've talked about so far. What can you do? What is an early first step that you can take that may be helpful? 

So finally, before we bring this session to a close, if you still have that pen and paper, I want to invite you to consider whether you would like to do a commitment exercise. And so when we think about the subjects that we've covered today, the first thing you can ask yourself is, what is one thing that I will either attempt or consider or reflect on or that I might even attempt to change based on what I've learned today? 

And the next question is, what steps will you take? What specific steps? It can be incredibly small, but they should be, as we all know, with smart goals. They should be very detailed. And they should be actionable and things that you're actually capable of doing. 

And then the next question is, how will you remind yourself? Can you put a prompt in your online calendar right now to remind you 30 days from now? A reminder pops up that says, remember your commitment exercise. What steps? Have you taken those steps that you committed to? 

And so finally, with those questions in mind, writing down for yourself what it is that you commit to at the end of this session when it comes to taking steps based on what you've heard to try to find meaning and purpose in your work. 

And with that, I want to thank you so much for your time today. I hope you found this session useful. And I want to wish you luck in the lifelong quest that we all face when it comes to finding meaning, purpose, joy, and work-life integration in the practice of medicine. I do believe it's possible. Thank you.

SPEAKER: Good evening, and welcome. I will go ahead and get us started while we have our last participants trickle in here. So my name is Courtney. And I will be the session moderator for tonight. 

On behalf of CMA Joule, we'd like to thank you for joining us for the early career learner speaker series webinar. CMA Joule is a Canadian Medical Association subsidiary dedicated to physician-led learning and leadership. And we've created this special series of webinars to provide you with the tools to navigate life outside of residency and the realities of practice. 

I'm speaking to you today from Ottawa, Ontario, the unceded and surrendered territory of the Algonquin Anishinaabe people. I would invite you to consider your own position with respect to the land where you live, work, and play recognizing that the land was home to other people and communities before settlers. Here at the CMA, we look forward to forging new culturally-safe relationships and contributing to reconciliation acknowledging that the injustices experienced by Indigenous people of what we now call Canada continue to affect their health and well-being and there is much work to be done. 

The CMA was recently involved in a film project called the Unforgotten. And I would encourage you to watch even one of its short segments as it was created to incite reflection and spark conversations and how to make meaningful change happen in health care. I'll go ahead and put the link in the chat here. so that's there for your reference. That's the Unforgotten. 

And so today's session will be recorded. And we strongly encourage you to ask whatever questions that you may have through the Q&A feature, which you'll find a the lower banner ribbon of your Zoom. So we know this is a challenging time for physicians, and we want to acknowledge our gratitude for the incredibly hard work, dedication, and sacrifices you all make even more so now than ever. 

We'd like to let you know that we have hundreds of resources available on the Physician Wellness hub to help physicians with their well-being. And I'll also include that link here for your convenience. So there that is our Physician Wellness hub link. 

And today we are fortunate to have a panel of Dr. MacNeill, Dr. Stigant, and Dr. Miller with us to present the talks today. And I will now pass the mic over to Dr. Miller. 

FIONA MILLER: Thank you so much, Courtney. Hello. And welcome to this session, which as you know, is part of the CMA Joule early learning series with this specific session put on in collaboration with Cascades, which is a new national initiative for climate action and awareness in health care that is funded by Environment and Climate Change Canada. 

I'd like to start by introducing myself and my colleagues and acknowledging the traditional territories from across Turtle Island where we are joining you from today. I am a professor at the University of Toronto. I direct the Center for Sustainable Health Systems and also Cascades which I just mentioned. And I'd like to acknowledge the land on which the University of Toronto operates and where I live. 

For thousands of years these have been the lands of the Huron-Wendat, the Seneca, and the Mississaugas of the Credit. And I'm very grateful to have the opportunity to live and work on this land. Next slide, please. 

I'd like to introduce you also to my colleague Dr. Caroline Stigant who is a nephrologist at Island Health. She's the Medical Lead for home hemodialysis at the Royal Jubilee Hospital and is a clinical assistant professor at UBC or University of British Columbia. And she's the Inaugural Chair of the Sustainable Nephrology Action Planning Committee of the Canadian Society of Nephrology. 

Dr. Stigant is speaking to you today from the traditional territories of the Songhees, the Esquimalt, and the Wsáneć Nations. And she's shown us here a picture of very oak meadow on Southern Vancouver Island where she lives, one of the most endangered landscapes in Canada. And these are landscapes that have long been cared for by the First Nations people through selective harvesting and control burns that purple flower, the camassia has a root bulb that was the primary starch in the local diet. And the acorn trees there were staple food in fall and winter months. 

I'd also like to introduce you to Dr. Andrea MacNeill who is a surgical oncologist at Vancouver General Hospital and the BC Cancer Agency. She is a Clinical Associate Professor at the University of British Columbia where she specializes in sarcoma and peritoneal malignancies. And she directs the Planetary Health Care Lab at UBC and helps lead Cascades. Planetary Health Care lab is one of the founding partners of Cascades is a national initiative. 

Dr. MacNeill is speaking to you today from the traditional territories of the Musqueam, the Suquamish, and the Tsleil-Waututh peoples. And she wishes to thank them for their stewardship of these lands, their generational knowledge, wisdom, and teachings. And with that, I'd like to turn to the context for our talk with you today. 

And the context is on the one hand, what we increasingly understand about the health and health system impacts of climate change. I have here on the left a couple of the reports that point out, although really it's not so much that IPCC report from last August that pointed to the physical science basis of climate change but the one that came out yesterday. I believe it was from the sixth assessment working group two on impacts, adaptation, and vulnerability that sets out the scale of the challenge for health and health systems, the adaptations required. And that other report there, which is from Health Canada, which is part of Canada's commitment to a national adaptation plan and figuring out where are the vulnerabilities for health, for health systems because climate change will and is affecting our health and is creating risks and challenges for the operation of our health system. So that's really the left part of this slide and the context for this conversation. 

The right part of this slide is the irony that the health care system, which is affected by climate is also part of the problem. So here we have an article that by my colleague Dr. Andrea MacNeill and her colleagues who did the first national assessment of the environmental impact of Canada's health care sector which produces almost 5% of national emissions, which is in accordance with many developed countries around the world. And taken together, the health care sector around the world Health systems around the world are would make as about 4.6 of global emissions, which makes it a very significant emitter among big emitters on the planet. So we have the irony and the challenge of having the health of populations, of individuals, and communities profoundly impacted in unequal and inequitable ways and the health system challenged in its operation and ability to function even as we know that part of what we're doing to deliver care contributes to the problem. Next slide, please. 

We are at a good time even if a challenging time because the other part of the context for this talk is the increasing effort to mobilize health systems and health professionals in responding to these challenges. And many of you will know that at the Conference of Parties Meeting COP26 last November in Glasgow health and health systems were featured even more than they have been previous of these international conferences. And indeed there was a very important health program pulled together by the WHO and other groups like the English National Health Service, which has been a global leader to galvanize national commitments across the world. And Canada along with the US and over 40 other countries committed to deliver both climate resilient health systems and health systems that are low carbon and sustainable. 

So we have now, I think, importantly for the first time a federal commitment and realization that the health sector is and needs to be a very active part of building towards a low-carbon economy by 2050. We know that several of the provinces are already moving in this direction, but I think this is an added impetus for action and support for action. And meanwhile, initiatives like Cascades and other groups around the country that we work with represents and tries to galvanize some of the capacity, which is growing and which many of you in the audience also help to represent. And so I think we are yes facing a challenging time but a time when there is considerable opportunity to collectively make a change. And with that, I'll pass the mic over to Dr. Stigant. 

CAROLINE STIGANT: Thank you very much. These are my disclosures. Next slide. So we've had an introduction here from Dr. Miller about this terrible situation that we're in. And in the upper left part of this graph is where we're going to start looking at the significant rise of carbon dioxide emissions, not news to anybody on this call but perhaps news that the concentration of greenhouse gases in our atmosphere is increasing 100 times faster than they have at any other time in history. 

And when I say history, I mean, 800,000 year history. We know this from scientists obtaining tiny air bubbles and analyzing their CO2 content from deep within the ice sheet. Also the concentration of greenhouse gases is double that of a historic average from pre-industrial times. 

And I want us as physicians to focus for a minute on the implications of physiology of a doubling of a physiologic variable like CO2, like pH, and we'd all understand the very dramatic effect that has on our body systems. And it truly enrages me that we're in this situation due to carelessness. And we will do better and we must do better. 

So these increase in emissions moving right on this plot, you can see through the greenhouse effect we've all heard how the temperature increases. And to reference, this problem, we're now on average from pre-industrial times over 1 degree warmer, that's the Earth at large. Canada because we're northern and the Poles are warming more, Canada has heated by 2 degrees and our North even more by 3 degrees. 

So some people might say, so what? What's one degree? What's three degrees? I can't even feel that. 11,000 years ago at the time of our last Ice Age the mean temperature difference between now and then was five degrees. And that is very alarming when you think that our North is more than halfway to the ecologic difference from an Ice Age ago. 

So rising temperature we've all heard it melts the sea ice. Again, the concern there being many ecologic implications and health. 40% of people live within 150 kilometers of the sea or the ocean. And although 150 kilometers may seem a long way away if it's flat and if it can be overwhelmed or if coastal water sources and sources of vegetation and livelihood are overwhelmed leading populations to retreat, we're talking massive, massive impact. 

Further to the right on this curve is the effect on weather patterns. And we feel in BC that we've been unfortunately witness to some of these events. So drastic weather and it may be wind, it may be rain, it may be too little rain, and too much sun and too much temperature. 

So let's factor in these ecological factors with what I would say are human factors. We live in a variety of different areas, perhaps a low-lying Pacific island, perhaps one of the coastal areas I mentioned, perhaps inner city in a poor area where there's lots of pavement and not a lot of cooling, perhaps in a underresourced country as an agricultural worker without a policy that might protect us from the heat of the sun or volume depletion. And through these different exposure pathways at the bottom are various examples of health outcomes. 

So I'll just walk from left to right across this slide. It's not too difficult for us to picture how extreme weather events might cause, for example, traumatic injury. We saw moving to the right here in BC the heat stress. 595 people died in British Columbia over the course of four days from heat stress, something that none of us were really trained to look for. 

Air quality. There's a longer pollination season, there's sort of natural allergens that may occur in the air, and there's also pollutants. We'll get to that air quality in just a moment. But significant triggers for asthma or COPD here and pulmonary infections. 

There may be too much water in places that water is not historically been. And I'll just jump to the right there about the vectors because that will affect insects, of course. And so here in Canada we've seen a rise in West Nile virus particularly in Western Canada and some tick borne diseases, particularly in Central Canada. 

The food supply and safety and social factors in my mind are intrinsically linked. There's been tremendous migrations of peoples already that I think have been incorrectly attributed to social issues, social unrest, war issues. But I think fundamentally there's a competition for land that is started that puts tremendous strife. 

People are on the move. We're competing for limited resources. There is food scarcity. And sadly, I think we'll see more of this. The next slide, please. 

This depicts these issues here in Canada. So they've sort of highlighted the key issues in each area, but these are by no means mutually exclusive to the geographic part of Canada that's featured. And I want to draw attention to northern Canada, again, with the significant warming that's happening there and the traditional loss of ability to maintain one's livelihood on the land. 

So there's a difference in where animals are distributed. There's a difference in the ice, the safety of being on the ice of living a traditional lifestyle. So tremendous anxiety for our northern neighbors. Next slide. 

So it certainly surprised me when I started looking into this area that one in four deaths worldwide currently are linked to the environment. And it surprised me even more that 2/3 of those are non-communicable. So I would have pictured accidents or infectious pathogens or the like. But if you look at the top 10 causes here, number one and number two are stroke and ischemic heart disease. So we're going to get into that. 

Moving to the left on this graphic of where is it happening, North America is relatively spared. And I actually don't think we're as spared as all of that. I think we're just attributing certain things to other causes or not recognizing the impact of environmental factors when we code deaths as being stroke or ischemic heart disease related. But we're also relatively protected because we're not as relatively as highly and industrialized area as the others. The next slide. 

So the fossil fuel component of air pollution is responsible for the majority of the deaths. And there's some data here on that. Next slide. So how might this happen? So I'm not sure if anyone has heard of particle pollution. 

I had not. This denotes one of the factors of the air quality warning and it's called PM 2.5 in some instances. These are 2.5 microns or smaller in diameter. There's not one chemical that makes up particle pollution. It's a grab bag. 

And it's variable by where you live and what sort of industrial activities or development is in your area. So it's made up of a mixture of combusted carbon and products, material called crustal material like concrete dust, sulfates, nitrates. And the point is they're all really small, and they bypass our upper airway defenses. They get deep down within the lungs. They can actually pass through the alveoli into our circulation, and essentially the air and the contaminants in the air diffuse into our body. 

And from that point we have activation of the systemic inflammatory response. And this is proatherogenic So this is borne out in a significant-- I haven't included the references here, but there's a lot of literature that looks at chronic exposure and increasing vascular endpoints as well as acute exposure leading to the more abrupt events and physiologies that are described on this slide, such as plaque rupture. 

So once the atherosclerosis accrues that plaque can rupture. We can have thrombosis an acute event. So that's the rationale for brain and heart events. 

I want to emphasize as well that the kidneys are implicated in this process too, being vascular organs. And one analysis has predicted that or has determined 60,000 incident cases of chronic kidney disease in Canada are attributable to this cause. So I think this is a silent wave that's coming. Next slide. I'll hand it over to my colleague here. 

ANDREA MACNEIL: Thank you, Dr. Stigant. Now, in addition to understanding the impacts of climate change on health which Dr. Stigant has just beautifully articulated, we also need to understand-- my slides are no longer advancing, perfect-- how climate change will imperil our ability to deliver health care in the way that we've become accustomed to. 

And this is an infographic that's published by Vancouver Coastal Health public health group depicting the impact of climate change not only on health but on health systems. And this necessitates what we call adaptation in the climate world, which is preparing for the inevitable impacts of climate change and building resilience into our system against future disruptions. And as Dr. Stigant alluded to. We in BC last year experienced a series of climate catastrophes that not only had devastating public health impacts on our general population, but also significantly interrupted our ability to deliver care. 

So during that heat dome our hospitals were so overwhelmed with heat-related illness that all elective surgeries were canceled for a number of days. During the historic wildfire season we had to evacuate hospitals or long-term care facilities from the interior of BC. And then the atmospheric river in the fall washed out critical infrastructure such that dialysis patients could not get to their treatments. I had cancer patients who could not get to their daily radiation treatments, and their oncologic care was significantly compromised by these events. 

Now I understand from my public health colleagues that this degree of disruption was expected but not projected to happen for years. And this is in keeping with yesterday's IPCC report that has painted a bleaker near-term future than was previously expected. And as Dr. Miller laid out in the introduction, there is actually a bidirectional relationship here between climate change health and health care in that not only are we and our patients impacted by climate change, but we are also significant contributors to the problem. The task of reducing our impact on the climate is called mitigation. And that's the partner of adaptation in the climate world. And these efforts have to be intentionally co-created. 

Now, if we apply this lens of the interconnectedness of human and environmental health specifically to the health care system, we arrive at what I have termed planetary healthcare. And I think that this concept begins with an expanded notion of our duty of care from simply that individual patient in front of us to other patients both present and future, to the general population, and to the planet. And this is beautifully encapsulated in this Lancet call for an updated Hippocratic oath for the Anthropocene that I would encourage you all to read at your leisure. 

A year ago, we published a framework for planetary healthcare with the purpose of conveying the scope and the scale of systemic transformation required and to try to dispel the myth that sustainable health care is equivalent to waste management. So I'm going to provide a brief overview of this framework, and then Dr. Stigant and I will illustrate the application of it to medicine and then to surgery to try to inspire you to operationalize it within your own practices. And the first thing you have to understand about this is that every health care activity has a footprint, every treatment you provide or test you order consumes material resources and energy and generates waste. So anything that reduces the incidence or severity of disease thereby decreasing the amount or intensity of care required is climate change mitigation. And to do this, we need universal access to preventive services and good chronic disease management in order to keep patients interaction with the health care system at the lowest level of resource intensity and to optimize their determinants of health to keep them from needing care. 

The second operating principle of planetary healthcare is matching the supply of health services to demand, which means avoiding both overuse and underuse of health care. Underuse of necessary services like vaccines and cancer screening leaves patients vulnerable to avoidable disease. Overuse of health services results in avoidable harms to patients, in financial harms to health systems, and to environmental harms. 

And inappropriate or low-value care is care in which risks or harms outweigh the benefits or care that will not influence your clinical decision making or change outcomes. I think that appropriateness of care is a neglected dimension of health care quality. And we know that it stems from both system factors like health care structures and funding and also from clinician and patient behaviors. 

And our third operating principle is decarbonizing health care or reducing emissions from the supply of health services. And this includes the classical notions of sustainable health care like green buildings, energy management, and transport fleets, but those have typically not been within the purview of the commission. We also in this tier have an enormous opportunity with respect to health care supply chains which we now know comprise the majority of health care emissions and ways of delivering care in more efficient, coordinated, equitable and low-carbon ways. 

Now, the literature describes three levels of social accountability in clinical care. And we've adopted this to create what we're calling a ladder of engagement for clinician action around climate and ecological health. The micro level refers to actions that individual clinicians can take within the scope of their day-to-day practice. 

Meso-level actions occur at an institutional level, so most often a hospital or a health system or within the local community. And macro-level actions are undertaken by governments, by professional societies, and regulatory and oversight bodies that have the capacity for sweeping top-down mandates across the sector. As clinicians, we can influence all of these levels by adopting an advocate role or assuming leadership and administrative roles within our organizations. 

We've operationalized this framework for the individual clinician and published this in the BMJ a few months ago. So I refer you to this for a comprehensive overview of planetary health care. But Dr. Stigant is now going to take us through a case study of nephrology to highlight the opportunities that are presented by a chronic disease for low-carbon resilient care. And she'll apply each of these operating principles to the treatment of chronic kidney disease. This could equally apply to other chronic diseases or to the practice of family medicine or other medical specialties. 

CAROLINE STIGANT: Thank you. I really echo what Dr. MacNeill had just said there about cause and consequence. Climate change causes kidney disease, and the management of end-stage kidney disease in particular contributes to this load. 

And reflecting on this, I think, nephrology practice is really at the nexus of all the issues that we're talking about today and it's an interesting case study. I don't know how many people are in nephrology focused on the line. I'm going to guess that most of you aren't. And so with you in mind, I've tried to bring in little snippets of other specialties and make this relevant for some of your practices and career pathways. So we have opportunity and obligation as I call it. 

So kidney disease is really common. All of you have looked after kidney patients, many of them you probably didn't even know where kidney patients they can have asymptomatic disease. And as you likely know, when kidney failure happens in other conditions-- be that cirrhotic liver disease, be that chronic infections, malaria, bacterial infections, HIV infection with diabetes, with congestive heart failure-- patients do dramatically worse. So it's a risk multiplier for all conditions. Through incidence of end-stage kidney disease is dramatically increasing. 

The International Society of Nephrology has called kidney disease the most neglected of the neglected chronic diseases. And on our watch, again, we have to do better. Marked increase in incidence of disease-- and just page down-- it's really more of it. It's projected now to be the fifth highest cause of years of life lost by 2040, dramatically on the rise. 

And the treatment for it is costly. I've shown you financial cost here. I should have included transplantation which is in some sources a half or a third of the cost of dialysis. 

But not only is it costly to the patient, it's costly to the funder. But it's costly to the environment. So again these are the three bottom lines that we're talking about today. And next slide. 

Huge personal impact here. There is increasing grief amongst the care team about the waste. There are questions about what can we do with this volume of waste. This on the right, the graphic is a photograph that one of my home hemodialysis patients took. This represents one week of her garbage, and it's only her dialysis supplies. 

This is not her regular household garbage. There's two other people in her household. The remaining weeks worth of her dialysis garbage supply is taken to her brother's house-- he lives in a condo-- so she won't have to pay for it. 

Otherwise they were billing her for it. They were sending her letters saying, don't throw so much garbage out. And she came back to us and said, what can I do? Next slide. 

We've heard very nicely in the preceding slides from my colleague about systems impact and again, the need for adaptation to these is really exemplified within nephrology. We have a disaster plan that is I'd say, fairly ironclad for the medical field. And rightly so, after the recent atmospheric river and the floods, a lot of our home dialysis patients in particular had issues of getting shipments to them in a timely manner, so, how to jump in with resources? 

And I want to draw attention and commend the amazing work of the group of people you see here. This is a group of hemodialysis nurses who worked in a town called Williams Lake. In 2017 the entire town had to be evacuated. 

So the dialysis unit-- all the patients, all the staff included-- they went to a community about 120 kilometers away. Overnight they learned how to use a new dialysis machine, and they welcomed their patients the next day. So there are some success stories here but we wish we didn't have to do that. 

There is a tremendous global impact on water, energy, and single-use disposable and the energy and pollution associated with that from our end-stage kidney disease treatments. And I haven't featured peritoneal dialysis, but the story is likely not too different from that. Next slide. 

So before we get into Dr. MacNeill's approach and our personalization of it, I want us to really stress this was conceptually very helpful to me when I first started thinking about this problem of how to reduce carbon without reducing health. And I just want to really drive the point home that we're not talking about rationing. We're talking about optimizing patient's health, but I think being smarter about how to do that. 

And some of the ways in non-nephrology areas that prevention some of these are obvious, like non smoking. But thinking laterally on being active-- bike helmets is an interesting prevention example; exercise regimen is another interesting one; and patient empowerment, perhaps people with depression or anxiety or various mental health problems to empower them with the skill set for self management, assisted self management of course. An example of a lean pathway would be for people who wish to be organ donors or even recipients to instead of have their tests coming over many days, to expedite them and coordinate them so that it's the same-day workout. That's an interesting concept we're working on locally. 

Low-carbon alternatives might be substituting dry powdered inhaler for a metered-dose inhaler because there are very potent greenhouse gases that are emitted in the metered-dose inhalers. And an example of an operational resource use might be reclamation of an anesthetic gas in the OR setting. So some examples to get you motivated and thinking. 

So I really want to thank the Canadian Society of Nephrology for their leadership and allowing us to put this group of people across Canada together. That's just really unrolling in the past few months-- Sustainable Nephrology Action Planning. We've got our own logo designed by my 14-year-old daughter, so a nice touch of home there. 

Vision and mission statements as you see here, and we're really big on verbs-- education, innovation, advocacy. We want to get stuff done. Next slide. 

So taking that framework, a lot of health promotion, disease prevention and chronic disease management is done in nephrology care certainly but a lot of it is done upstream of nephrology care. We really need a primary care, referral care, and referral source care to engage with us. And so I thought I would just have a rather than say, please manage chronic diseases effectively, I'd dive into that a little bit because I think everybody on the call probably knows that it's tough to do effective chronic disease management. 

So I think some strategies that I give you are learning how to have motivational assessments and discussions with patients, scratching below the surface a little bit, demonstrating really your contract with them and the fact that you care about their outcomes. An example of that is for the cessation when I'm talking to patients, I don't pretend to have the perfect approach to this, but I always ask people who've stopped smoking, how did you do that? 

And I'm very pleased to hear occasionally they say, you cared and you asked me to do this. And I think that we can't underestimate the effect that we can have in some of our patients' lives. So that's one example. 

I've put on the left here are some various ideas but reducing barriers to access. So we've got webinars. We've got podcasts. We can speak to patients on their terms, maybe having social media champions, laypeople, embracing certain causes. I think we can be innovative in how we speak to people. 

A few more points on that. I think that everyone on the call really needs to have-- every practitioner-- a rock-solid approach to management of vascular diseases. So diabetes, ophthalmology even-- you're going to be looking after people with hypertensive eye disease, people with diabetic eye disease-- liver and chronic liver disease NASH, vascular surgery, cardio, the list goes on. So everybody should know where their guidelines are found, the targets that you're treating to, inform your patients, challenge the patients to meet these targets. It takes work to manage this effectively. 

Also this notion of Health in All Policies framework, and here's the advocacy role, the macro system role for colleagues. You could take on a variety of causes depending upon your care areas, interest, and expertise. And one example might be campaigning for agricultural use of antibiotics or not, pesticides, taxing or subsidizing foods to promote healthier eating habits, just lots of different ideas. And next slide. 

To get more to the kidney world then in this one, I think, there's some important messages from kidney care here. The management of hypertension is cost effective. And I find it interesting in Canada that we pay for end-stage disease management, but I think we should be doing more to fund preventative treatments. 

Another newer example of a treatment that thankfully we have now are SGLT2 inhibitors. And it would be wonderful to see those funded in target populations to reduce the risk of people progressing to end stage. No one wants to reach end stage. 

For those who do reach end stage, they want to transplant. They don't want to be on dialysis. So we have to look at ways to increase transplant. And I talked about a lean service care pathway previously that may optimize that. 

We are industrial scale orders of lab testing. And I think we need some literature around the guidance which are opinion based, sort of best practices based for how often we should be measuring lab work. It's my observation that most of the major changes in patient status when they're started on dialysis or medications are changed usually there's a symptom that they come up with. And I think that's an area ripe for a study of how often is it symptom or patient driven that comes to our attention that we would then initiate additional testing on the background of their baseline testing. 

In terms of appropriateness of care, we can dialyse people to closer to home. And there may be some savings there with carbon emissions associated with travel. And Choosing Wisely is a really important one. I would encourage you all to look at the Choosing Wisely website in your specialty and in related practice areas and even internationally. There's some interesting ideas. 

And for us on dialysis, we want to make sure that the right people are receiving dialysis. There is an option of conservative care for those who would felt not to benefit from dialysis care. So ensuring that those patients are optimally supported in a non-dialysis care trajectory is also really important. And we're starting to look at and communicate the importance of environmentally-preferable purchasing. Next slide. 

Because we're a major users of equipment and single-use products-- I think, this one is a bit easier to picture-- we have opportunities to work with our industry partners to challenge them to come up with lower carbon and zero-waste treatment options. We're hoping to work with transit authorities and getting low-carbon options to mandatory visits. Of course, hemodialysis patients have to attend health care appointments three times per week. They don't have the option of a virtual care appointment. So decarbonizing transport is a big one for us and perhaps looking at innovative materials like more biocompatible or better-managed plastics. 

I'll hand it over to, oh, not yet. I have a few more to go. So back to you, to the audience then what can I do? You have to think and function a little differently. And I hope we've given you some ideas here. 

And you can just open up to all of these documents. Thank you. So on the micro front, I would say first and foremost, measure your own carbon footprint. There are some good websites here. 

And challenge yourself to do better in your own realm, and it becomes fun. It's quite addictive. And it is very helpful to get you thinking about where the major sources of emissions are. 

It's critical to get patients to have time outdoors. We know there's data that's effective for chronic disease management, but also people will advocate more for nature preservation when they have a relationship with nature. So to compound our caring for the environment, this is really critically important. I've talked about the preventative and hopefully effective preventative practice. 

I've taken to having patients look at the weather report and pay more attention to the weather report. Make sure you've got a few weeks supply of medication. In the case of dialysis patients, make sure that you've got a few weeks supply of your home stock. 

And make sure that you've got a personal disaster plan as well as the program having one. And a special reminder here of underserviced, racialized, and special needs populations of which we have many, they have unique health needs. And please consider them in your planning. 

We can reduce materials use when possible. I'll focus on that in just a moment. Another ask that I'll have a message for you is, please in the institution in which you work, whether it's a larger clinic or whether it's a hospital setting make sure that every one of them has a sustainability plan. 

There's all kinds of resources, including on the handout that we've prepared for you for how your institution could approach. This is key because you cannot function in a vacuum on. This is systems based. And then we've challenged you to think big as well. 

So on this last of my slides I wanted to show you some of the things that we've looked at. I've partnered with a hospitalist in our hospital, and we've got a planetary health aligned group. And we started thinking about things that really bugged us. 

And this is another sort of starting point that I would suggest that you could look at. For me, it was walking into a patient room and seeing five or six of these single cups on a tray. It's just ridiculous. 

So we've got our purchasing people getting the blue ware Tupperware, getting rid of these single-use. We've got campaigns on appropriate use of nitrile gloves. So there's lots of opportunity in your care setting. And I'm leaving you with the last look in my last slide here with some local inspiration throughout the seasons, some beautiful sights to nourish the soul along the way. 

ANDREA MACNEIL: Thank you Dr. Stigant. And now we're going to switch gears and in our last few minutes think about surgery to complement the medical perspective you just heard. I'd like to try to convey the scope of the opportunity that surgeons have and how we can best focus our efforts. 

The OR is widely recognized to be one of the most resource-intensive health services, and it's a significant contributor to the environmental impacts of health systems. In 2017, we published this carbon footprint study of three hospitals in different countries. And it was a very granular carbon accounting exercise of everything that happens in the OR because at that point I wasn't thinking more comprehensively about the practice of surgery. 

And we compared three tertiary care centers in different systems. And our findings showed three key things that I want to convey to you today. One was around the disproportionate impact of inhaled anesthetics and specifically desflurane on the OR carbon footprint. All inhaled anesthetic agents are greenhouse gases but one desflurane fluorine is disproportionately worse than the others. And we found that the British Hospital, which didn't have that drug on formulary because it's more expensive had 10% of the anesthetic emissions of the North American hospitals where it was in widespread use. Our 

Second key finding was around energy consumption we showed that each HVAC system-- so heating, ventilation, and air conditioning systems-- account for 90% to 99% of OR energy use. And we showed the importance that clean energy has on our carbon footprint. As you can appreciate in the second line of this table, in Vancouver our energy footprint was one third of that in Minnesota because our electricity is from hydroelectric sources and theirs is coal powered. 

And the third key finding was that emissions generated in the manufacture of the consumables that we use in the OR outweigh those associated with their disposal. So I realized that the mountains of waste that we generate in the OR are the most visible and gut wrenching of our environmental impacts. But in fact, the choice of consumables that we use in the first place is far more important than how we dispose of them. 

So these three findings have been instrumental in guiding our mitigation efforts ever since. And since the time of this study, I've come to appreciate the role of decisions made and actions taken outside to the OR and how these contribute to the footprint of surgery and how we can intervene along the entire continuum of care to minimize our environmental impacts while providing higher quality and more equitable care. So just like Dr. Stigant did for nephrology, let's just walk through the framework with respect to a surgeon's practice and appreciate that even if we can't influence OR's HVAC system we still have tremendous opportunities for impact. 

On the health promotion front, cancer surgery is a significant component of many surgical specialties. So we can embrace opportunities for cancer prevention or early detection. This includes things like optimizing cancer screening programs but also adopting an advocacy role. 

And I can think of no better example of this than Dr. Frances Wright shown here who is a melanoma surgeon at Sunnybrook. And she I believe is now the head of surgical care for Cancer Care Ontario. She was instrumental in lobbying the Ontario government to have tanning beds banned to use under 18. So it's one more thing here. 

With respect to chronic disease management, many surgeries are to treat the consequences of chronic diseases. So much as Dr, Stigant described, there are opportunities for good chronic disease management and optimization of comorbidities with the goal of preventing people from arriving at the point of ever needing surgery. So as she mentioned-- liver, kidney, lung transplants-- these are all the result of end-stage organ failures which in many cases have modifiable risk factors. She also alluded to vascular surgery, which is driven by modifiable risk factors, and there are many other examples. 

Preoperatively we have a number of different stewardship opportunities or ways that we can drive appropriate care. As surgeons, a big part of our job is determining who would benefit from surgery. And despite adages about hammers and nails, we do try to exhaust options for non-operative management and ensure appropriate patient selection. 

There have been 13 RCTs showing that knee arthroscopy is no better than physiotherapy for the treatment of osteoarthritis, and yet it took years for that data to have a clinical impact. And up until just a few years ago this was still the primary indication for knee arthroscopy in Ontario. Part of patient selection is shared decision making, which refers to the process of situating evidence within a patient's own worldview and helping them apply their own values and preferences to it. And RCTs have shown that up to 20% of elective surgeries would be unwanted if patients had access to unhurried, transparent, honest information. 

Our current uncoordinated care pathways often result in patients undergoing unnecessary investigations and treatments before arriving at their definitive treatment providers. Adhering to evidence-based guidelines for preoperative investigations can avoid non-value add tests. CIHI and Choosing Wisely released a report in 2017 looking at unnecessary care across seven areas of primary and specialist care. And they showed that up to a third of patients having low-risk surgery had unnecessary preoperative tests. 

Post-operative complications are bad for patients but they also necessitate additional resource consumption from needing ongoing care. So optimizing patients for surgery to minimize their risk of complications is a component of planetary healthcare. In the post-operative setting, we have opportunities for stewardship within our inpatient management. 

And Dr. Stigant alluded to the frequency of bloodwork. We did a study showing that we were over ordering unnecessary bloodwork in 76% of our patients. So there's a huge opportunity here. 

We also need to critically appraise current practices like, the value of daily chest X-rays in patients who are intubated or have chest tubes or reflexive PPI used for gastric protection in a critical care population. This has actually been shown to cause harm. And we need mechanisms to deadopt these practices that add no value. And lastly, I'd suggest that we need to encourage best practices which are obviously part of quality care. But demedicalizing patients as quickly as is appropriate after surgery avoids iatrogenic complications like UTIs or bacteremia from central lines all of which prolong stays increase the resource intensity of care and they're bad for patient outcomes and experience. 

And of course, within surgery we have many options for the delivery of low-carbon care. As I mentioned in our study, we showed that HVAC systems are responsible for the majority of OR energy use. We also found that most ORs are maximally ventilated 24/7 whether they're in use or not. And we modeled scenarios in which we set them back to the minimum acceptable level when not in use. And we showed that we could cut our energy consumption in half. 

With respect to health care supply chains, reduction is the highest level principle in what we call a circular economy. Several studies have shown high levels of systematic waste in surgery with many consumables that are routinely opened and rarely or never used. There's a group in Toronto that's applying AI technology to inform strategic streamlining of surgical instrument trays and showing considerable cost savings and material resource use and waste. 

I would suggest that we default to reusables. Almost all of the studies called lifecycle assessments that we have comparing different products have shown significant environmental savings with reusables. So when in doubt, default to these, and then use your advocate role to try to influence your organization to preferentially purchase reusables. 

Now, even appropriate care can be inefficiently delivered, so better coordination can reduce emissions both from patient travel and from repeated interactions with the system. And this is particularly relevant in cancer care. Oh, my WIFI froze. 

SPEAKER: We can still hear you perfectly clear. 

ANDREA MACNEIL: I'll just stop my video and just keep talking then. That is the most unfortunate place for it to have frozen. Can you still see the screen share? 

SPEAKER: Yes, we can. 

ANDREA MACNEIL: I don't know why that just happened. But let me get back to that slide and we will resume. I do apologize. We are here. Here we go. 

Yes. So what I was saying was that in cancer care patients often need to see specialists from surgery, medical, and radiation oncology but we're really bad at coordinating to provide those together. Sorry, I don't know what's happening here. 

IT systems can allow care to be delivered remotely. So in BC I can order imaging anywhere and view the results. And this avoids patient travel, improves patient experience, and it also avoids duplication of care from incompatible systems. And finally, appropriate use of virtual care can also avoid patient travel, and it's an important component of health equity in opening up access to specialist care to our rural and remote populations. 

I'm very quickly just going to, I think, finish on this example because I want to give us time for Q&A. So I'm just going to give us an example from anesthesia which we would consider part of the provision of surgical care to demonstrate the co-benefits of low-carbon care and the alignment that we see with improved quality and patient experience. So as I mentioned, inhaled anesthetics are potent greenhouse gases. And you can appreciate from this bar graph on the top right that strategies that include inhaled anesthetics showed in the top two bars are orders of magnitude worse for the climate than alternatives like total intravenous anesthesia or regional blocks. 

We've recently surveyed a number of institutions that implemented regional anesthesia programs for breast surgery either immediately, before, or during the pandemic largely motivated by a desire to avoid aerosols. And they have universally reported overwhelmingly positive outcomes from both the patient system and societal perspective. Very quickly, patients do not have postoperative nausea and vomiting like they do with general anesthetics. They have very good analgesia which facilitates their recovery, allows them to go home sooner. This has allowed us to have a higher throughput and begin to address our COVID backlog of surgeries. 

And from a social perspective, it's also allowed us to reduce opioid prescribing which is particularly important given that public health pandemic. I'm going to skip over this last bit and just finish so that we can have some Q&A, and reinforce the idea that both mitigation and adaptation are necessary components of a low-carbon resilient health system, that incorporating planetary health principles into medical practice includes opportunities for prevention, stewardship, and low-carbon care, and that this is often higher value care with many cobenefits for patients, systems, and society. So with that, I'll wrap up and turn it back to Dr. Miller to moderate our discussion. 

FIONA MILLER: Super. Thank you very much. That was terrific. We do have a couple of questions in the chat. So I'll start with a question from Lindsay Russell about the extent to which events like COVID have impacted health care. Have they minimized the carbon footprint? Or are there other ways in which they've influenced practice? 

ANDREA MACNEIL: I can go first-- 

[INTERPOSING VOICES] 

--and say there's both good and bad. Conceptually, the pandemic has been good in demonstrating the agility of historically behemoth and non-agile health systems and demonstrating our ability to mobilize and response to an existential threat. I would suggest we need to channel that same energy into our response to the climate crisis. 

It has been good in motivating innovations in health care delivery, such as the delivery of regional anesthesia instead of general anesthesia which has those myriad cobenefits. It has unfortunately also prompted a lot of uptake of single-use consumables and generated a lot of new medical waste. The WHO released a report a couple of weeks ago around pandemic waste, specifically PPE and the impacts are staggering. So hopefully we can kind of shift course on some of those negatives and capitalize on some of the lessons learned and the innovations that we've gained from the pandemic to help chart a better path forward. 

CAROLINE STIGANT: I have a few thoughts on that as well, and would echo a positive and a negative in that regard. And I think the rise of virtual care in chronic disease management has been an obvious benefit. Patients really like it. 

And I think it helps us to have a better continuity of care with a lot of people who have been sometimes challenging to bring into the office setting. Sometimes that's a personal preference and sometimes that's geography related. So that would be an obvious plus. 

But a downside on a medical perspective is the late presentation with disease that we're seeing. We've heard a lot about people staying away-- maybe the chest pain isn't an M.I., I'm not going to go to the emergency. 

And so we're seeing a lot of later presentations with sepsis, . certainly with heart problems. Those are the two that jump to mind. But echoing what you said about the disposables, just marked increase. 

FIONA MILLER: Great. So I'm going to just put the last two questions forward because I know we don't have a lot of time. So one is just about preparing the future health workforce. Is this part of training curricula? Is it in the medical training programs? 

And I know this varies. I don't know if you have thoughts on that. And the other is sort of about somebody who's beginning their practice as a rural family medicine resident and asking about resources to help build a sustainable practice And? How to move this agenda forward. So who would like to start or take on one of those? 

CAROLINE STIGANT: I'll start this time. Fiona, So I actually developed and give a lecture on this subject in UBC undergraduate medicine. And this was really my getting my feet wet and trying to become an expert in this area. 

So I would say that you can become an expert. My co presenters today are two of my professional idols. And it's very humbling to me that two years later, I was asked to share this platform. So you can do it is what I would say. There's a big need that's here. 

I know that I can speak for UBC any way that they're looking at how to integrate this across all aspects of undergraduate teaching, but I think it needs to get more into postgraduate teaching. And in the conversations I've had with some of my colleagues-- I'm mid-career, so mid and later career colleagues-- this is not on their radar at all. And so I think that there's a need for CME resources at the Royal College level to step up and support physician learning across our career pathway. 

ANDREA MACNEIL: Fiona, did you want to speak to Cascades efforts in that respect at all, the resources available for training? 

FIONA MILLER: I mean, we do have a fundamentals course and we're starting with CMA in partnership program of physician leaders. And we have other sort of training programs that Cascades is moving forward. And I think I think Caroline's point about needing to get to people in practice is vital and clearly curriculum, though, I think is quite variable across the country. CFMS Heart is working very hard, the medical students are working very hard to get this into-- so I think it is being taken up. From Cascades perspective, continuing professional development is certainly part of our contribution. 

CAROLINE STIGANT: The medical students really deserve a shout out there. They've been very effective very vocal in their campaigning. And it shouldn't have had to come to Med students campaigning for that. 

ANDREA MACNEIL: I can answer the last question if you like, Fiona, and feel free to weigh in here both of you. The Canadian Coalition for Green Healthcare has some resources available around green infrastructure, if you will. So the question is specifically around low emissions buildings and tools and such. Healthcare Without Harm is a US-based advocacy organization that similarly has publicly-available tools and resources. That may be something that we're able to offer eventually through Cascades more on the clinical-delivery side than the infrastructure side but in terms of how to tailor a practice to be optimally resource efficient and low carbon and sustainable. 

FIONA MILLER: I would add that the climate change toolkit for health professionals which CAPE no longer has on their website but you can still find it. Chase has it and others. That's a useful resource. 

But again, the office perspective, Cascades does have and is building a suite of primers and infographics that are more clinically-focused opportunities in clinical areas. So that's certainly something that's particularly clinically near as is as Cascades I think very much where we think there's value-add contribution to make. But yes, right now it's a bit scattered but there are resources certainly. 

And with that, is this talk going to be posted somewhere so we can link to it? Yes, we believe that it will be in due course. But CMA Joule has a sort of a plan for this, but I think we'll go back to our host when we're ready for the answer to that question. Before I hand it back to her, Caroline or Andrea, do you have a final quick line you would wish to convey to the audience of final messages that you would like them to hear? 

CAROLINE STIGANT: I would say thank you for caring, and spread the message of care. I mean, this is bigger than us. This is bigger than our medical practice. We need to live differently that's the bottom line. We don't have to suffer. We just have to live differently. 

ANDREA MACNEIL: And I would add to that this is not additional to other core values within medical practice. This is part of patient safety, quality, equity, social value creation, all the things that we are aiming for as health professionals. So do not consider this in competition with those as some sort of competing priority but part and parcel with high quality, equitable care. 

FIONA MILLER: Great. Thank you so very much for this. And I'm going to pass it back to Courtney to close the session for the CMA. 

SPEAKER: Excellent. Thank you so much. So on behalf of the Canadian Medical Association, we want to give a thank you to our panel for taking the time to discuss this important topic. And a big thank you to our early-career learners for joining us tonight. 

Just a couple of things to mention before you go, . I'm just about to post a link in the chat here. So that link right there that you'll see we ask you to quickly fill out the survey. It takes about two minutes to provide your feedback. 

And then also if you're interested in being caught up to our transition of practice sessions for residents and recent graduates, the sessions will be available to medical schools across Canada from July 12th to 18th. And you'll see the link for that right here. And the schedule as well as registrations for these courses will be posted within the next two weeks. 

And then one last thing that I'll include in the chat, so this will be an environmental sustainability and health care handout. So I'm just going to drop this here if it will allow me. It might take a quick minute for that one to drop. 

But otherwise, we just wanted to say thank you again for your participation. Take care. And stay safe thank you.

Hi, and welcome to relationship tips for busy doctors. I'm Dr. Marcia Kostenuik And I'm delighted to be here with you today for this session. I wish I could sit down with you one on one and answer all of your questions, but I'll do my best to share with you some of the favorite tips and strategies that I share with physicians I work with one on one in psychotherapy or in my coaching sessions. 

There are also strategies that have been useful to the doctors who've taken my courses on parenting, relationships, and burnout prevention as well as mindfulness. And I'll even share some of my psychological first aid tools with you as well. So thank you so much for being here. And let's get started. 

If you would like to connect with me in the future, you can get free resources on my website at drkostenuik.com. The best way to stay connected with me would be to join my newsletter. I try to send out some information every month as well as offer some free sessions for you to connect with. 

If this session generates any questions for you, you can email me at Marcia@drkostenuik.com, and I'll do my best to get back to you with some answers and resources if I can. And if you'd like to connect on social media, I'm on Instagram, Facebook, Twitter, and LinkedIn. So I'm happy to connect with you that way as well. 

So in this session, we're really going to learn some of the deeper concepts from psychotherapy where it really helps if you have a better sense of who you are if you want to be in healthy relationships. If you don't have enough self awareness or the ability to put yourself in someone else's shoes, it's going to be very hard to have enjoyable, successful, and effective relationships. So sort of the ground zero we start with is knowing yourself. 

Now, of course, that's the work of a lifetime. You're not going to know every aspect of yourself but to the degree to which you can start to become more self aware. Sometimes that means getting feedback from other people, which is sometimes difficult. But I'm going to give you some ideas here about how you'll be able to take feedback in a healthy context. So before we attempt to correct others, we need to sort of address our own, whether it's faults or flaws or shortcomings or just the different challenges that we have, things that don't come easily to us. 

So first thing to think about in any relationship if it's with your patient or let's say a friend or your partner is what are you bringing to the table. Think of for example, if you're anxious or you have ADHD or you're angry or maybe you have a chip on your shoulder or maybe you tend to be very optimistic. These are examples of the kind of attitudes, personality traits, and variables that you bring to the equation with a patient or anyone you're interacting with. 

So it's not just like in vitro, in a test tube. I mean, people are responding to you moment by moment. You are already responding to me-- My eye contact, the way I talk with my hands, you're getting a sense of my voice, my pace. 

Some of you might choose to speed me up as you're listening to the video. Some people might slow it down and rewind. So it's really important 

Now, if I could see you right now face to face, I'd already be getting tons of data on how are you responding. Are you sleepy? Are you tired? Do you need me to be a bit more energized? Do you need me to speak calmly? I would be picking up on that. 

I have to do my best in a recording to appeal to a broad audience. But hopefully through the skills that I've gained as a physician, a clinician, a teacher, a coach, and a therapist I can do my best to try to consider all the types of audiences that could be here and still be able to connect with you as best I can even though it's a recording. 

So the idea is to get comfortable with your strengths and your weaknesses and also your blind spots. So there's things I do, facial expressions I make I'm not even aware of them. I see them later on the recording and I might even judge myself. But I also have to be aware of my strengths-- what I have to share with you, and what I really want to help you with today-- and also my weaknesses-- what are those tendencies I have that I can try to keep in check? 

So ego strength is that idea of really being able to be OK with your weaknesses and also to own your strengths, not to be falsely humble. There are things and that you're good at. The area of blind spots means we all have aspects of ourselves that really we don't realize we do or we might even deny we did it if somebody said it to us. 

So if someone says to me, you talk with your hands that's not a blind spot. I realize that I do that. But there are other things I do that I might be quite shocked, I might be hurt or offended, I might be sad, or frustrated and think, gosh, I didn't know I was doing that. So there's always going to be blind spots. 

And sometimes therapy and coaching are formats where you can get to be more aware of your blind spots but in a safe way that doesn't feel harsh or critical, and that you can be sure it's from someone who has good intentions. It's not a jealous or angry friend or colleague. It's not somebody to get you. This is someone who really is supporting you and advocating for you, so you can be safer in receiving feedback from them. 

So we all have what Young called the shadow self, which just means aspects of our ourselves of which we're not aware. It doesn't mean the dark side. In fact, some people might be unaware of their softer side. 

They put on a harsh front but they're really a softy inside and maybe they don't even realize that. So shadow self simply means that idea that we're not really consciously aware of it. And like I said, this is the work of a lifetime. 

Why is it important to know about the shadow self or know about some of your unconscious tendencies, the things that make you say and do the things you do? Well, if you're not aware of what you're bringing to the table, you're not aware of your personality, your tendencies, kind of the way you're calibrated, then you're going to unconsciously bring that into relationships. And you might actually kind of blame it on someone else or not understand why a dynamic is going so poorly or not the way you would have expected. 

So I think is it a movie or a book the Emperor's New Clothes where he doesn't realize that is he naked. I don't even really know the story. But the idea is he looks foolish to other people because he's not aware of how he actually looks. 

And many of us-- I'm a Gen Xer-- we don't like getting feedback. Millennials tend to seek feedback. But really it's what you do with that feedback and whether you're willing to take it, to be objective about it, and to be open minded about the feedback that you're getting. 

So in therapy and in coaching you may start to become more self aware and then integrate this into your sense of who you are. You might have thought you were really serious but other people actually find you gentle, or maybe you didn't think you were very funny but other people think you have a great sense of humor. So you start integrating these things and being more aware of the way others perceive you and have a fuller more mature sense really of who you are. 

So physicians actually have a higher than expected rate of adverse childhood events. So this relates to that shadow self and knowing yourself because sometimes we don't realize how much we've been impacted by trauma. It may not be what you consider large trauma, but it could be still something that created betrayal, a loss of trust, and has really activated your nervous system and put you on guard, made you hypervigilant. It can increase your risk of post-traumatic stress disorder-- PTSD-- which is common in physicians through vicarious trauma. And those who have trauma already in their childhood or background are potentially even more vulnerable and susceptible. 

So these are the kind of things you want to be aware of. If you're a very early physician or resident, this stuff might sound like gee, is this really relevant. When I speak to retiring doctors, older doctors they tell me this is the most relevant. This is the stuff that helps you be able to your job, to get along with people, to not dread the patient list, and to have healthy relationships with your children, your parents, your siblings, your spouse, your partner, your friends, your colleagues. 

So this material in this session I feel it's golden material. Some of it might seem simple to you, some of it may be complex, but even the simple things are not always easy. And that's why we need to remember them and kind of elevate them in importance and realize this is very valuable. 

I certainly have found good success with my patients and my clients and also in my own life. I share with you the things I've learned through my own struggles. And I've had many challenges like many of you have. But these strategies will really help you be able to integrate all the things that have happened already and find maybe healthier ways to navigate your relationships moving forward. 

So adverse childhood events can be growing up in a family where there was a divorce that caused a lot of stress and tension in the family or a sibling went to jail or if a close family member had a serious mental illness, addiction. These are just some of the examples. Abandonment and physical or emotional abuse would be other examples. 

So sometimes when I work one on one with physicians they say, oh my goodness, I never really stopped and took a good look at myself and what's going on in me. And to be honest, many people don't want to really take a good look. We sort of repress, suppress. So consciously or unconsciously we kind of don't want to go there and be thinking about what are my flaws and weaknesses. 

But as you do this, you actually also become able to own your strengths and then to also figure out where those gaps are in your knowledge and abilities and seek the right kind of help to grow and learn and have better relationships. So don't worry. We're all a work in progress-- my husband, my kids, me. And I try to be honest with them on the things I'm working on. And also I enjoy when they respect the things that I'm good at and we can all appreciate one another. 

So don't feel that you're broken but hopefully you'll be open minded enough to realize that you do have relative areas of strength and weakness. You may have seen this Japanese pottery where when it's broken it's repaired with gold. So instead of throwing it out or it's no good it's broken, we're actually highlighting those areas where it broke. And really I think, all of the struggles and difficulties or brokenness that I have or have experienced I've had to mend and learn coping strategies and learn new techniques or figure out what made me vulnerable, and then repair that and hopefully share the gold with you of what I've learned and what I've been able to help others with. 

So where to go from here? If this session activates things for you and you do start looking at inside at some things that are maybe quite difficult that you haven't dealt with, then be sure to reach out for help. If it's to activating, if it just feels like too much or it's confusing, likely you're going to need to talk to a close trusted friend or family member, your family doctor, a therapist, somebody who does counseling, family counseling, couples counseling, a physician coach. 

So whatever resources you need, please be sure to reach out. There's also mdpac.ca is the Medical Psychotherapy Association of Canada, and they have therapists available on their website who might be able to work with you and the PHP-- the Physician Health Program-- with the CMA. So every province has that available for you as well. 

So let's do a few, I think, I have three quick tips to start with and then we're going to talk about some obstacles to healthy relationships and how to overcome them. So if you want to watch this in part, maybe either take a pause now or hang in for the next three quick tips, and then the next part will be overcoming some of those obstacles. So if you need to manage your time, I would recommend doing it in that way. 

So here's our tip number one. You're not always right. You might think this sounds ridiculous, but sometimes us doctors come across as being know-it-alls. And maybe we've been trained to be a know-it-all. I know in my residency training it was drilled into me that I kind of had to have the answer for everything and to never be hesitant, to never be questioning, to sound completely confident which I think is actually quite a dangerous way to train a physician. 

So recognizing that you might have evidence and training and suggestions and advice but it doesn't mean you are always right about everything. It's the best evidence we have. It's the data we know. It's what is commonly recommended in Western medicine. So those are examples where when you're interacting with patients you're giving them the best information you have. 

And that's a different position to come across from then this presumption that you are right and you are all knowing. Probably none of you do that. But sometimes we come across that way and we don't even realize it. 

So if it's with your marriage, your partner, your child, it's the same thing. We are much more approachable we have a healthier dynamic when people get a sense that we're sharing our view, our opinion, our needs, our wants but not in a way that insinuates or insists that it's our way or the highway. In my relationship course, we talk about being influenceable. 

So even as a physician talking to a patient, are you influenceable? With your partner, with your kids, are you willing to take in some new information and hear it and consider it? Or do you just block it out and you assume that you have it correct? 

So this is an area that can lead to patient complaints. It can lead to medical errors and disastrous medical outcomes. So the older you get, I think, in medicine you learn to really listen to your patient and make sure that you are considering other options and that you don't get that tunnel vision and focus where you assume you're right and you're not taking in any other info. 

But what if you're really right? I mean, sometimes you just may have a fact that somebody doesn't have and you're quite certain that it's correct. I think in the same way just not to be righteous, not right fighting, just to share with them maybe this is what the top 20 cardiologists have found is most useful, and the research showed this medication was superior to not taking medication in this certain population if you really want to get technical. But the idea is still that you're not pushing your idea, but just simply sharing this is the information you have available and you think it's really good. 

Sometimes I'll share that, I think, the evidence I have is kind of weak so we're not sure. It remains to really be determined. So that might help a patient consider things differently rather than you saying, there's the best evidence to show that this medication is the most effective. They might say, well, what would you do? And so you're giving your opinion, you're sharing but you're not telling them how it is. 

For relationships you might have heard that expression, do you want to be right or do you want to be married? I might have heard that many years ago from Dr. Phil. I'm not sure. But it's a good one. 

So quick tip number two, listen and validate. In my experience working one on one with physicians and teaching physicians in groups and in courses, we tend to be really bad at validating. So we often haven't been role models what it feels like to be validated. 

We're more used to somebody correcting us or being harsh or being strict, perfectionistic, really pushing that conscientiousness. So that if I said something to a role model or leader, that kind of figure in my life, they might have corrected me rather than saying, oh, it sounds like you're really upset or you seem really disappointed. I have done this with people as well. 

So what do I mean? If someone says, I'm feeling sad because I lost my cat, listening would be obviously making good eye contact, paying attention, noticing are they crying, do they look upset. So you're really listening to their voice, their words, and their body language. Validating would be acknowledging what they've told you that they're very upset. They're sad about it. 

So rather than saying, oh, I'm sure the cat will come back, so that's invalidating. So you can see as doctors, as a mother, as a spouse I frequently invalidate people in my life because I want them to feel better. I kind of want to jump in and solve their problem. I want to tell them how I think it really is. 

I want to be optimistic, something like that, rather than to say, oh my goodness, that you seem really sad or how close are you with your cat? What does it mean to you? And sort of finding out a little bit more. 

So as a physician if a patient's telling you something is causing a symptom and you don't think that causes that symptom, let's say validating would be saying, so if I'm hearing you right, when you fell off your bike that's when you first noticed this symptom happening? Is that right? And you're thinking that maybe falling off the bike is what caused the symptom? 

So you see how you don't have to agree with them, but you're trying to put yourself in their shoes and understand what they're thinking and feeling without correcting them and without jumping in to solve it or fix it or give them suggestions. This is really hard to do. So check with your loved ones and ask them if you tend to validate or invalidate if you really want to get some honest feedback whether you're good at this or not. 

So let's see. I could go on all day about validation. But I want to make sure that we get all of these tips in and use your time as effectively as possible. Which person is listening? I know this seems obvious to you. 

But physicians nowadays with EMR it's getting worse and worse where we're not making eye contact or we're looking at our phones or a tablet. So in order to listen, you really need your hands empty, so no cell phone, no computers, no mouse in your hand. And really a phone should be in your back pocket not visible, not even just turned over on the kitchen or the dining room table while you're having dinner with your family or loved ones. So we really want to give people our full attention. 

As a physician if you do this initially at the beginning of your encounter and again at the end, you're going to have a much healthier interaction with your patient. They're going to feel heard. They're going to remember that the first thing you did was to really listen, and the last thing you did was to really connect with them. 

Again, this can reduce violence. It can reduce complaints, litigation. Patients really need and want to feel heard. Plus, as you listen, you're going to get better information, you're going to make more accurate diagnoses, and you're less likely to make errors and the kind of mistakes that lead to litigation. So this is just crucially important. 

I teach this to psychiatrists I mean, these are experts who've been listening for their career. And those who are fantastic at their job will thank me and say, we can't be reminded enough how important and valuable it is to listen in these healthy ways with validation and really attuned to the person. 

And yes, try the golden minute. So that's 60 seconds of just listening with reasonable eye contact, a comfortable level of eye contact, not to be odd or confrontational but to show them that I'm really here and I'm really listening to you. So 60 seconds. Try that with your patients and see how that works, see what kind of response you get. 

And I think you're going to find people are going to be much more satisfied with their interactions. You're going to have a lot less frustration and less conflict with your patients. But don't worry, we're going to talk about how to handle conflict effectively towards the end of this session. 

So if someone says you weren't listening to me, then you aren't effectively listening to them. They don't feel heard. So again, that's not for us to invalidate them and say, well, I was listening to you. The point is they're giving you feedback that whatever way you are listening it doesn't feel authentic and effective to them. 

So if you have enough ego strength, you can ask them, what you're doing? And how you can listen better? What helps them to feel heard? That can help in your marriage or partnership, can help with your patients, it can help with colleagues at work, all of your relationships. 

If you have ADHD or you just tend to get easily distracted, obviously you want to put away those distractions and show that you're fully present. Because really you might not be able to remove-- you might not be able to focus with the distractions there. It's just not possible for you. It's not available to you as a skill. 

So in that case, you're going to have to eliminate distractions. Go to a quiet room. Turn off the television. Put the phone away. Whatever it is that you need so that now the person can really feel that you're listening. 

And quick tip number three is to respect healthy boundaries. So those of you who might have been through therapy or coaching may have learned a lot about healthy boundaries already. It's a common theme that comes up for people. So important to respect what is mine and what is yours. 

We say, where do I end and the other person begins? So with a doctor-patient relationship you've probably learned about healthy boundaries and professionalism. The patient's not your friend. They're not your family member. There is a division there. 

However, you also have a sameness, a common humanity. You're not all that different from a patient in terms of you know what pain feels like, you know what frustration feels like. So you want to connect and be attuned to your patient, but also have that healthy boundary. 

If it's in your romantic relationship, your partnership with your kids, the same. A healthy boundary means work-- this is also part of ego strength-- we're giving people credit for being their own separate self. I'm not there to rescue you. I'm not there to bully you. 

I respect that you have your own opinions and ideas. They're different from mine. And I'm collaborating, I'm sharing with you. It's like a team member in your health journey if I'm the doctor and you're the patient. 

So we're separate selves. We're both to be respected as individual selves. And we're not there to enable or rescue or boss somebody around. So again, there's lots we could talk about with healthy boundaries. 

But another thing that you can do here is to recognize if it's a patient, what is their strength? Maybe you're frustrated with them but you realize they're always on time. They always say thank you at the end of the visit, something like that. Or they've been able to eat well and exercise and take some care of themselves. So you might recognize some of their strengths and not only their weaknesses. 

So you want to stay within the boundaries of your role. So really this is so helpful in romantic relationships and couples as well as parenting. So you don't want to, for example, in parenting we say never do for a child what they can do for themselves. Don't sort of disable them, so to speak, by undermining them and just doing things for them when they could do it and get the satisfaction of realizing they're competent and they're capable, they're individuating, they're maturing. 

And if it's with your patient, again, sometimes residents in early-career physicians will say like, the patient won't listen or how can I get them to do this. And we talk about really being more of a teammate and sticking to your role. You can't make someone do anything. Your role is to provide them with the best information you can, maybe to give them your opinion if that's what they're wanting, which they likely do. 

And when you speak to them that way they're just far more likely to respect what you have to say and they won't feel as defensive that you're kind of pushing something at them. They feel they have choice. You're interested in their opinion and view as well. So sticking to your role and not being that rescuer can be very important. 

If it's other relationships-- your sibling, your neighbor-- you don't want to doctor your neighbor. You don't want to be a mother to your patient. You need to stick to your rules. So ask yourself what would a sister do in this case if you're the sister? 

What would a kind helpful neighbor do who has a healthy boundary? So make sure you stick to the rule you're in that defined relationship, like, you're not your child's doctor or your spouse's doctor, for example. So you want to stick to the actual role. 

Of course, be professional always. So some doctors during the pandemic have been just so burned out, so spent just ready to snap. We'll talk a little bit about that neurobiology in a moment. And I'll talk about how to breathe and ground yourself so that hopefully you don't snap. 

But at least if all else fails, try to stay professional with your language, your listening. If you need to pause and take a break, take a break. I really just hope you won't do something that you can't undo or say something that you can't unsay. 

And any things that you share with your patients, certainly as a psychotherapist I think of this often and I check in with my patients and get feedback on this, if I share something personal, it's relevant to their therapy. It's not because I want to talk about, I don't know, myself or my family or a problem. It's because it's relevant, it applies, and it could help them. 

So you don't want to just reveal personal things or something too personal. Really have that self awareness-- is this helpful to the patient? Is it going to make the patient feel more trusting that I'm down to Earth and it's safe to share with me? Is it going to make them recognize, hey, this is a professional relationship not buddies? So you have these certain ways you interact to let the patient know that you're safe, you're listening, but also that you're not like best friends, that there's a professionalism there. 

One last reminder it's just that you're not an imposter. Some physicians, it could be early-career physicians or not. It's often more often female physicians. It can also be in minorities or people who felt that they had to work extra hard to kind of earn their position and respect. And they feel like an imposter. 

It's not a real syndrome. It's simply a phenomenon. And I think the more you realize your strengths and weaknesses and own your strengths, own your training, and be very real about all the stuff that you don't know or just don't yet have experience in, you won't feel like an imposter. 

You're simply going to feel like everyone have areas of weakness or blind spots, things you don't. Hopefully things you're willing to learn if it's your job to learn them. And you're going to be able to own the strengths that you have. So 

I always say, if you're a new judge on the Supreme Court and you're the new person, you're simply the least experienced. So you're not an imposter unless you are an imposter. But if you're not an imposter, you legitimately have your degree and training and you've been hired, you've been through all this process, then sometimes all it means is that it's new to you and you just don't yet have a lot of experience. 

And if you're not overconfident or excessively humble but rather own the strengths, be aware of the weaknesses, I don't think you're going to feel like an imposter anymore. Please get in touch with me too if you have questions on that. I'd be happy to try to help clarify if that's something you're still struggling with. 

So next section-- this is a place to pause if you need to pause or pick up on later. And if you can keep going right through, that's great. But we're going to get now into three obstacles that just make it so much harder to have healthy relationships. So the last section was what to do, and these are some of the things that make it hard to do those things, hard to have healthy, comfortable, safe, relaxed relationships. 

So one of my goals with this kind of session is that you eventually get to a point where if you're a physician who has a patient list that there aren't names on there that you dread, that you actually have an approach and a way to understand people and work with them. I do think that's possible. And I'm also hoping that if you're struggling in relationships at home personally with friendships, colleagues, your partner, spouse, children, that these tips can be so valuable. 

And if those personal relationships aren't going well, it's really hard to focus at work, to bring your best to work. It's hard to enjoy any part of your life when your most precious, important intimate relationships aren't going well. That's why I've developed courses and sessions like this one to help physicians also with their parenting and partners and romantic relationships and burnout because all of this is related. 

So what is amygdala hijack? So the first obstacle we'll talk about, amygdala hijack means you've really been activated. So maybe a patient said something really insulting or hurtful or your partner criticized you or your kid is screaming. 

I don't know what's happened, but something has got you on edge. You're activated. Your nervous system is firing. Your sympathetic nervous system is on overdrive. 

The amygdala is signaling, and you're getting a fight, flight, freeze, response or appease, appease meaning, OK, I'll do whatever it takes to just keep the peace. So you can see how that's a problem as well. Sometimes I go through all of those in detail and how to address each type of reaction. 

But for the sake of staying focused on relationships, let's at least talk about that sympathetic overdrive. What to do when you're really activated? And the problem is the prefrontal cortex gets less blood flow. There's less electrical activity. There's less functionality in that part of the brain that actually allows us to be empathetic, to put ourselves in someone else's shoes. 

So you get it? Like, now you're on the defense. They've activated you. You don't care about them or how they're feeling. Now you're feeling defensive, you're feeling attacked, maybe you want to fight, maybe you want to get out of there, maybe you just feel frozen. 

So you also lose that ability to be flexible, to problem solve, to have insight, that intuition you have, maybe diagnostic skills that you need. All of that goes offline so to speak. It's much less functional when you're activated. 

So when the pandemic started I created psychological first-aid tools where I kind of package together in an easy-to-remember mnemonic some of the many techniques that we use in mindfulness, psychotherapy, grounding techniques for trauma, techniques that really work to help you quickly come back to a calmer state. So hopefully, you'll remember to use them. I have free videos and PDFs on my website of these psychological first-aid tools. 

So you don't have to take any notes. You can get them there, the ABC123 tool. I've actually recorded and I guide you through it on the website. So that's at drkostenuik.com. 

And so the idea is to do a moment of self awareness, notice your body. So that's A. B is some particular types of breathing with a slow exhale or box breathing. C is counting, which is a quick grounding technique. You count things that you see, hear, and feel, and that brings you back to your senses back in the body. So that ABC helps ground you back in your body, get you breathing, reduce hyperventilation, reduce high heart rate, so reduce the risk of a panic attack as well. 

Then we move into the more cognitive skills, the 123. And many people try to use cognitive skills right away. But as you saw on that amygdala hijack slide-- now by the way, Daniel Goleman who wrote the book Emotional Intelligence he coined that term I believe, amygdala hijack. So I just like to credit that. 

As you saw, you can't really use your cognitive skills when you're in that physiological state, that activation of fight, flight. So that's why I did the ABC first. And then the 123, 1 is to focus on what's the one thing to do. Let's say it's a relationship or a conflict, what is the one thing you want to get out of this encounter? What is the goal? 

Number 2 is two strengths. So it's calming to think, what are two things I'm good at? This is a strength I have. This is something I know. This is something people tell me I'm good at. Focus on a couple of strengths have, maybe strengths that can help you do that one thing you need to do. 

3 is three things or three things you're grateful for. So they've actually shown neurobiologically that generosity and gratitude are the fastest ways to activate happiness circuits in the brain. So you're going to have a more positive affect. This is like a mood regulation skill. You're going to feel better if you think of three even very small things that you feel grateful or thankful for. 

So that ABC123 technique can be done right in the heat of the moment. You can do it as a daily practice so that you get good at it. And if you do mindfulness and daily practices regularly, you can actually thicken the prefrontal cortex. It's going to be stronger just as if you were weightlifting and you're making your muscles stronger. 

And you can quiet or reduce the hyperactivity in the amygdala. And that's functional and structural, and it plays out in the way we interact with others. So for example, it might be a lesson startle reflex or you're less likely to become defensive. 

So again, you can get all of that on my website, drkostenuik.com. Follow the recording. Print the PDF. Use it at work. Use it with your patients. Practice it on your cell first. 

And I've had great feedback that this has helped people with insomnia. It's helped them to help their patients. And some of them just read it right there for the first time as they're helping somebody. So I prefer if you practice it first. But I've basically scripted the whole thing here for you so that you can guide yourself or you can guide someone else in it. 

And then the box breathing was one of the forms of breathing that we do in the ABC123 tool. Box breathing is an equal length of breath in and equal length holding it, same breathing out and holding. So for example, breathe in 2, 3, 4. 

Hold it in 2, 3, four. Breathe out 2, 3, 4. Hold it out 2, 3, four. So that's the B part of breathing. The other technique there's various ones but one of them is just to breathe out more slowly or just to generally slow your breathing if you can. 

But that box breathing is used by Navy SEALs. It's been shown to stop panic attacks. It can reduce your heart rate and blood pressure. So highly effective breathing technique you can use right away even if that's the only thing you do to try to calm yourself. You could teach this to your kids, a kid who has emotion dysregulation and now they have a technique to help calm and soothe themselves. 

So the other thing you can do is help make other people feel safe. So remember that amygdala hijack it's a fight, flight response. The idea is that we think we're in danger. So if you want to have healthy relationships with other people, they're going to need to feel safe around you. 

Did you know that doctors are automatically scary? I don't care how friendly you look, how smiley out you are, if you're voted the nicest person in your hospital. The problem is just due to the nature of our relationship with patients and that power differential, if you will, due to the control we have over resources, over getting an X-ray, getting a prescription. So there's automatically this differential, and we risk really making people feel afraid or bullied. 

What happens is you can enact or re-enact a dynamic where somebody felt bullied before and then they automatically are feeling bullied by you even though you're not a bully. So you have to-- you don't have to. You can do whatever you like. I recommend you work at finding ways to make yourself seem approachable and less intimidating. 

As I'm saying that, I know in training some people are learning to probably sound intimidating and look busy, which means you're not really listening, you're not really being present, and you're not making people feel safe. It's terrifying to have a doctor not listen to you. You're trying to tell them where it hurts, what you took, what happened, information so that they can help make a good assessment and they're distracted and not listening or they're making you feel so scared. You don't feel safe to share with them-- do you think I could be having that pain because I did XYZ? 

They're too scared to tell you. They think you're going to judge them. You're acting busy. You're checking your watch. You're in a rush. They're not going to tell you the information that you would need to make the accurate diagnosis. 

So if you've been trained to seem unsafe or scary to people, that's unfortunate. Hopefully, that hasn't happened. But it's never too late to learn how to be someone who makes people feel comfortable. Another thing you can do is smiling but it has to be a genuine smile. 

So I tell residents and physicians, check what your still face looks like, your sort of flat face. I know my neutral face looks angry or not very pleasant. And sometimes we look intimidating and you don't realize it. So take a look in the mirror what your neutral face looks like. 

And you can actually work on it having a slight smile as you approach somebody, not a phony smile, not something plastered on, something genuine. But you may need to counteract the way your face naturally goes in order to help people feel safe. Of course, with masks on it's harder. Doctors tell me they smile with their eyes. 

You can have a gentler tone of voice that sounds welcoming, both the choice of your words and the tone of your voice. I tend to tilt my head. I'm not sure which, I think, it goes this way more often. But I'm kind of tall, so I think I tilt my head in a gesture that I don't want to seem like I'm towering over someone. 

I'm not that tall. But another thing I'll do is sit down if I can or get myself at a lower position than someone to really show through my posture that I'm not scary and intimidating. One of my favorite things is if you can be on the same side is your patient. 

Now, some of you if you're new to this, you might think this can't matter. I assure you the impact of these things is so significant. It literally could prevent you from getting sued or I hate to be dramatic, but from getting stabbed or punched. 

If you enact someone's history of trauma so you accidentally are creating this feeling of re enacting a power dynamic that has been problematic to someone or traumatic, it can even trigger someone's PTSD. And they may be interacting with you as if you're somebody from their past. If somebody is already seeming violent and activated, you can help make them feel safe by listening and validating, and then they're not going to punch you or somebody else in the department. 

So your body language, tone of voice, physical direction that you're standing and sitting makes a huge difference. And it really can keep you safe. You can use this with your kids as well. We're pretty big and intimidating to our children-- same with a partner, spouse, or friend. 

So one of the best ways to make people feel safe is to listen skillfully, to show them I'm here, I'm listening, I'm interested, I'm curious, I'm present. Now, they feel safe. They also will think that you're intelligent because I mean, that's just been shown in research that when you listen well, people see you as more intelligent. And it really is intelligent to listen to people and to make sure that you're getting the right story, to clarify, ask questions, make sure you're hearing it correctly. 

So another thing you can do is to use neutral time. So this also can be used for conflict resolution. But if you're all activated and you just can't get yourself calm and regulated and back into that prefrontal cortex rather than the amygdala hijack, you might need to wait and just discuss things at a neutral time. 

As a mom I used to tell my husband with the kids that I'd say no, learning is happening, like they're totally activated. So it's not the time to preach, maybe it's never the time to preach. It's not the time to teach. There's not a lot of cognitive activity or learning going on. So maybe you can coregulate, breathe, get calm or get yourself calm or maybe they get calm. But if they don't, it would be better to wait and talk about the issue at a neutral time when one or both of you aren't activated in that amygdala hijack state. 

If it's with family, yes you can schedule a family meeting. So even with one of my teenagers we now book something once a month at a neutral time just to check in how is this going? How is that going? Maybe there's a problem area. 

If it's with your spouse or your whole family, your partner, a blended family, you can pick times where you meet maybe with just the kids or just with your partner. Go through the schedule, do around of appreciation-- what do we appreciate about each other? Don't try to tackle anything too big at first because you don't want to turn them off of these kind of couples meetings or family meetings but eventually you can start tackling more difficult subjects. 

And when you do this at a neutral time, it's scheduled in advance, people are in their prefrontal cortex. Hopefully you can keep them there and not get them activated through good listening and through validation. And now you can really problem solve. 

With your patients I love to do this kind of thing at the first visit-- just establish some boundaries some rules while everybody's calm. So if it's a concern about a prescription renewal for a controlled substance, talk about it early when everyone's neutral that you don't ever want them to run out of their prescription because you've seen people get really upset. It's scary. It's disappointing. 

So this is my policy to make sure you never run out of your prescription-- we do this, we meet every so often, you leave a phone message, or you call the office, whatever it is. Tell them what your policy is and what will happen if they don't follow that policy that sadly they may end up very angry and frustrated because they won't be able to get what they need at the last minute. So you can prevent so much conflict with your patients by having these neutral conversations, setting expectations and limits and boundaries early and/or at a neutral time. 

With families, couples, even with patients we all have different needs and wants. So at a family meeting or if there's conflict-- I'll talk about this in a moment-- we may need to negotiate, and we want to consider everybody's needs and wants. The patient needs to get out of pain. 

I need to prescribe them something safe and that is within the rules and limits. So we have different needs but we can look at it that way and try our best to meet everybody's needs. And I'll talk to you how to do that in negotiation in a moment. 

So obstacle number two is empathy. So it could be too much empathy, which might surprise you or too little empathy. There's also different types of empathy. Cognitive empathy is really more thinking about how somebody might be feeling or thinking and you being aware of that. So putting yourself in their shoes. 

Whereas emotional empathy typically means you're feeling emotionally what they're feeling. You can even have somatic empathy and you physiologically feel what someone else is feeling as if you got punched in the gut or they have a headache and you can feel pain in your own head. So it's really the emotional empathy, maybe somatic empathy too that tends to be more problematic, not so much the cognitive empathy. 

I do other talks just on empathy. I don't want to get distracted because we're focusing on relationships, but it's a really important concept. If I had to give you the bottom line, it would be really want to understand what type of empathy you have that you're strong or weakened and what type of empathy the other person has or doesn't have Because otherwise, we really misinterpret things. 

If you have low empathy due to autism or your brain would light up on a scan the way somebody with psychopathy the way their brain would light up. That might mean that the areas we tend to see activated with empathy aren't activated. So you're just not feeling what people feel. That doesn't mean you have to be an antisocial psychopath, but it may mean you need to take active effort to really learn how other people feel or ask them and to take that into consideration because it may not come naturally to you. 

So too little too much. The problem with too much is you get that amygdala hijack. Remember what the amygdala hijack the prefrontal cortex goes offline so you lose your empathy. So you have so much empathy that you're feeling so much, but if they feel pain and you feel pain or they're angry and you're feeling angry, you get so activated. 

If you can't regulate it, you're not able to remain empathetic. You're not able to use cognitive empathy. You're not able to respond compassionately. So it's a terrible irony. 

Sometimes I work with the nicest doctors who are so empathetic and caring, but it actually can get in the way and get them into trouble. Sometimes they finally lose it. They'll just blow. They'll just yell in anger because they're feeling so much of it. They sometimes feel they need to get away from somebody who's in pain. 

If it's your child or your partner and they're suffering with a chronic pain condition or illness or mental illness, it can just be incredibly exhausting to be constantly feeling what they're feeling. You may want to escape it or you may be angry at them. So you see you're not really showing them compassion. 

If you were less empathetic or you just had more cognitive empathy, you wouldn't feel the pain. You wouldn't be getting a pain signal. You would be thinking, gee, that's really hard for them. I wonder what I could do to help. 

So high cognitive empathy could be helpful. But I talk about, what can you do with who you are? You can't completely change your brain, but you can learn to regulate the emotions, get back into that prefrontal cortex, and then you can act compassionately. 

So I already mentioned about too little empathy. And so what I do is try to help you, for example use the ABC123 tool, try to regulate yourself. If you're feeling someone else's pain you're getting a pain signal, regulate, and then be aware what could I do to help this person within boundaries not enabling, not rescuing, not outside of your boundaries or rules, but what would be a reasonable thing within my role that I could do to assist this person to help reduce their suffering in some way? But see, you need to regulate yourself first to be able to have that kind of empathy and that kind of practical compassionate action. 

So also when I teach burnout I think high empathy really puts some people at high risk of burnout. Like we said, it's exhausting. They'll call it emotional resonance where you're feeling what someone else is feeling, and it makes it so difficult to stay objective and to stay still focused on how to help someone else because now it's just all about you suffering. 

So empathy fatigue is probably more apt sometimes than compassion fatigue. It's that excessive empathy, and it's exhausting. And like I said, you may block it or want to stop being around someone who's in pain. 

And you may not even want to go into the hospital or your clinic or wherever you're working because you just can't bear to be around pain anymore. With burnout I find it's like your nervous system is saying, stop, safety, danger, I can't take anymore. And then we push through it. I've certainly done that. 

So we need ways to regulate and understand the healthy boundaries and ways to recharge your own batteries. My burnout program is called Recharge to Prevent or Overcome Burnout. You need ways to make sure your cup is full and you have self compassion enough so that you have something left to give to others otherwise, it can just lead to exhaustion, empathy, fatigue, and burnout. 

So what I meant by empathic resonance is you're feeling with the other person's feelings. If they feel pain, you're getting a pain signal. You might have noticed on one of the slides I wrote, when you actually act with compassion you get a reward signal, like a dopaminergic signal. 

Doesn't this make sense when you think about it? We feel so rewarded when we help someone. I teach mental health skills, psychotherapy skills to residents and, oh, we always we love helping people. And so I work with the residents and say, but what if your patient isn't getting better or they aren't going to get better quickly? It's slow or there's a chronic process. 

We have to learn to be with somebody pain and suffering without being able to rescue or save, sometimes without being able to make a really big clinical difference but just to be there to support them. In yoga and in mindfulness we call it holding the space even in psychotherapy. Can I hold this space to let you feel your feelings? It's hard to do because you're getting that pain signal. Again, try the ABC123 skills to help regulate yourself and have some self-compassion because it's hard on you. 

So the idea here is in this case, it was a parenting example that the kids are angry. And the parent notices they're angry but pretty soon the parent starts feeling angry. And all sorts of thoughts start coming with that. You're not feeling sympathetic or compassionate. You're feeling angry too. 

So sometimes with parenting I've seen the children of physicians come to me and really find that their parents are self-centered and self-focused. And it's confusing because again these are like the nicest, compassionate, caring doctors, but if they have high emotional empathy and emotional sort of exhaustion empathy fatigue, they really become self-focused. And they just want to stop other people from being in pain because they don't want to keep feeling the pain. So it gets interpreted as being almost narcissistic and self-focused. 

Now, this is confusing because generally with true narcissistic personality disorder you're going to see low emotional empathy. But the weird thing. I have found in my practice and in teaching and with my coaching clients is high empathy strangely can lead to similar behaviors. So that's why I really work with both ends of that spectrum and helping people become self aware and self regulated. 

So one of the keys is once you're regulated you hold that space. You let them feel their feelings. This goes back to those slides on listening with validation. That's why it's so hard to validate. 

You want to stop their pain-- here, take this. Here, do this. Here's some quick advice. You don't want them to feel pain because you haven't been trained maybe as a physician to hold the space to allow someone to express themselves. 

This is stuff I learned from becoming a yoga teacher and guiding meditation and doing psychotherapy. So we need to be able to contain and hold and stay present even in the face of somebody else's complaints and pain. That is crucial. It just seems critical that we would have learned that really well in medical school. 

So again, the idea is to uncouple the emotional from what you're doing. So that's where rescuers, enablers, codependence they get this feeling and then they compulsively do something to make the other person stop feeling bad. So maybe they give them the drug they're addicted to rather than hold the space and have a healthy boundary, do healthy helping-- what I call healthy helping, which is within your role and that actually is going to lead to a healthier outcome for the person. 

So it's really important to self regulate, notice the emotion and not just compulsively rescue or just compulsively yell or get angry or create unnecessary conflict, for example, with patients. So these healthy boundaries are one of the solutions. And we've talked about that already. 

So the summary of that was to convert that empathic resonance. If you're aware of what's going on and you have these strategies, you can regulate and convert that into a compassionate action. What's a small thing I can do to relieve their suffering? If it's a patient complaining or getting activated and you're feeling activated, you can stay regulated. You can listen and hold the space. 

Compassionate action might be just that, that you listen, you stay present. You might be the first person who's done that for them. And it's actually therapeutic in itself. 

And then you may recognize your ability to say, let's see what we can do to help. Maybe you can't do the things that came in yelling about and demanding, but I can see you're in pain. I can see how difficult this is. Let's see what we can come up with that will be helpful and that is available for me to help you with. Good. 

So obstacle number 3 is conflict avoidance. So many doctors grew up either with a poor role modeling of how to deal with conflict, maybe there was yelling and anger or violence, or it was avoided and everybody just kind of pretends to get along or they look like they're getting along but nothing deep or meaningful is ever being addressed. So all sorts of different ways we may have grown up where we didn't really learn how to address conflict head on. 

If you did learn healthy ways to address conflict in your family of origin, that's awesome. Good for you. This is going to help you a lot. You can actually be a role model for other physicians, and they can see how you are able to handle conflict. 

So you're going to need to be able to deal with conflict. It's just part of life. I mean, to have a healthy relationship we need to be able to have different opinions. Conflict doesn't have to mean fighting or disrespect. What I'm meaning is just that we have different views and we're going to have to somehow work it out. 

Why is it so difficult? Why is conflict so difficult? Oops, sorry. So why is conflict so difficult? It's often because we've been activated again-- the amygdala hijack. So you don't have access again to those functions of the prefrontal cortex like problem solving and empathy. 

So we often have just also had bad experiences, and now we would rather avoid it. Some people just want to be people pleasers, they want to be nice so they think it's nice to avoid conflict. But really certainly in your marriage or couplehood, partnership, romantic relationship, intimate relationship you can't have intimacy if you're not able to negotiate conflict. You need to be able to listen to what other people are going through. You need to be able to hear their differences and show that you are inflexible meaning you're willing to take in that information and reconsider things. 

You might not always change your mind completely. But you're really not going to be able to have healthy intimacy in your close relationships if you're not able to address the things that create conflict. I think what I mean by that. 

Solution. Get comfortable with conflict. So what I mean is get the skills, practice with low-stakes conflict, practice the skills we're going to talk about. Many of the things we've already talked about here like listening, using your facial expression and body language to not be so scary to show that you're safe. All of those things we've talked about already are going to help you be able to deal more effectively with conflict. 

So validation, remember the slide on wants and needs? Paying attention what is the patient meeting and wanting, what is my child needing and wanting. Let people feel their feelings. 

If the patient's angry, guess what? They're allowed to be angry. It doesn't make sense to invalidate and say, well you shouldn't be angry. They are angry. It will be better to listen, create safety, and coregulate. 

And understand why they're angry, what is it that they're needing. If you can regulate yourself, you can problem solve and collaborate now. And you can stay creative and empathetic and be compassionate about how they're suffering without getting defensive and reactive. 

You're going to need to be compassionate with yourself. It's hard. If someone's yelling at you, I mean, who wants to be yelled at? Who wants to be in a clinic and somebody screaming at you or insulting you? It is hard, so you do want to give yourself some compassion as well. It's not easy to be in that situation. 

So with negotiation I teach a technique that I've sort of adapted from the book Getting to Yes. I think that's William Ury and Roger Fisher's book. So it's kind of an old-dated book. 

I think there are some old examples and things in there that might not be politically or culturally appropriate. I'm not 100% sure, so just be cautious. I've had different feedback from people. 

But what I teach is the general concept is number one, listen. Most of your negotiation or if there's a conflict it's going to settle down if you get really good at listening. So you're going to have to stay regulated to be able to keep listening. 

Then step two would be maybe to share how you're seeing it, what your need is, what you want. I want to help you with your pain as well and I need to follow certain directions to do what's in your best interest. So you might share your view. But that's less than 10% of the power here. 

And number three is a rule or standard. So sometimes let's say if it's your teenager, the rule or standard might be the speed limit is 50 kilometers an hour. So number one, I'm hearing you. You were driving fast. You weren't paying attention. 

You were chit chatting. And this is what caused an accident. My view is I'm so scared and worried. I don't know if you've been speeding or what happened. And third is the rule of that is the speed limit or you're not going to be able to drive now because we can't afford insurance until you make some money and save it or whatever it is. 

So just examples of spend more of the time listening and validating, then share maybe your needs, wants perspective and then something objective. So it's not like head-to-head combat. A way I illustrate this if you're a visual person is to recognize three times maybe at least or maybe nine times as much listening versus the speaking. 

This is really hard. Look how long I've been talking to you for. So doctors are used to being the ones talking, and we're going to need to turn that around in all of our relationships if we want to have healthy ones. 

Now if somebody wants all your data information, that's great. But when there's risk of conflict, really important for you to listen. Stay regulated. Put the problem on the table, meaning try to go side by side not head to head and really try to look together we have the same problem. 

If it's a lost prescription or the patient's in pain, it's a problem to both of us but we're being impacted differently by the details of the problem. So try to collaborate and negotiate together to work that out. Come up with solutions that are going to make sense and address each of your needs and wants reasonably. 

Of course, with a patient the goal is to stay within your ethics, to do what's in the patient's best interest. It's not all about you, but you also need to follow the rules. So be reasonable about listening to and understanding their needs and wants, and be realistic about your requirements as well. 

If you want to know more, I have a lot of details on these things in another video. It's a free video. I think it's about an hour on how to say no kindly and without the guilt. So that's again about limit setting and being able to say no. 

It can help with relationships. It can help prevent burnout. So I added that as a bonus video in my Recharge to Prevent Burnout program because so many doctors had a hard time setting limits and saying no kindly. And I go through a lot of this stuff in detail in that video. 

Tune in to relationships is a relationship course that I've done as well to help physicians in their more intimate personal relationships. A lot of these tips and concepts are examples that come from there. There's lots more available, so please feel free to reach out and connect with me if you're wanting more of this. 

So now you know remember way back talking about ego strength, know thyself, knowing who you are, what you bring to the table, get personal help if you need it? Maybe there's a lot of stuff there you haven't unpacked or uncovered. Maybe there's just a little bit that you would benefit from addressing. You don't have to go through all the depths of your whole life and past history, but there may be a certain area that it would help you to be able to talk to someone more openly about it. 

Learn how to stop that amygdala hijack by regulating. Use the ABC123 tool. Use mindfulness. Use the breathing techniques. Become self aware. Various mindfulness techniques, self compassion-- these are going to help you. 

Then you'll be able to either keep the empathy you have rather than getting exhausted or maybe use cognitive empathy or perspective taking if you're someone who doesn't have high empathy to be able to take compassionate action with other people. Have those healthy boundaries. Don't be rescuing or bullying people. 

We're side by side. We're a team here. Our needs and wants both matter. And hopefully now you're going to be able to address conflict more directly and not always have to avoid it or act in a way that you appease people or you see more intimidating or bullying. 

I'd love, if you have a moment, to share with you just the idea of repair. And really all I mean, for the sake of this session is if you've messed up, it's OK. You can repair. I mean, yes we can't unsay or undo things that's why I'd like you to learn to self regulate and for example use that ABC123 tool, but there are ways of repairing. 

And the more you learn these techniques, you're going to be able to repair earlier and earlier and even right in the moment. Maybe you're getting defensive, you pause, you breathe, you regulate, and you realize what? I wasn't listening. Let me try again. I want to really hear what you're saying. 

So you can repair right in the moment with your patient, partner, kids, friend, whoever. So it's never too late to repair. You have to allow people to feel their feelings. Maybe they're hurt, angry, bitter, resentful, we have to let them feel that but we're still able to acknowledge that we feel badly for the pain, sorry, that it caused them. 

That's me staying on track for you because we're going to finish up now. And I teach my physicians to always use timers. That's one way of limit setting. So I apologize for that noise, but it's actually kind of helpful to realize that these are the techniques that I use myself as well. 

So you want to acknowledge that it did cause them pain and suffering and you are owning that and recognizing that, and you have the intention, the wish, the desire to do what you can to repair that. And sometimes that repairs it, just the fact that you are talking to them about it and acknowledging it. These can be called fractures or micro fractures in your doctor patient relationship. And if you repair those, your patients will respect you more and you can not have to dread the patient on the list because you've done the repair. 

They know you're influential, you're not a bully, you're willing to take responsibility and ownership when something didn't go well only for what you've done. I mean, you're not apologizing for things you didn't do or didn't do wrong, but to be real that you could tell that something caused them hurt or suffering and you would really like to acknowledge that and address what you can to help make it better. So of course, you might have tons of examples. I wish I was with you one on one to go through them to be able to assist you that way. But hopefully at least you can see that this is possible. 

And there is a summary and resources, so a handout that I've prepared that accompanies this talk. So that will be on the Joule website. So be sure to check that out. The video on limit setting is on my website, drkostenuik.com. Email me at marcia@drkostenuik.com if you want other resources. 

My website has all sorts of resources on relationships, communication, mindfulness, meditation, yoga nidra, which is yogic sleep that I guide, courses that I teach, links to other people's free resources, crisis services where to go to find a physician who does psychotherapy. So all of these things are on the website. I try to keep it up to date with more and more resources. And my Recharge to Prevent Burnout program is on there as well. 

So, wonderful to spend this time with you. I hope you've gained maybe some insights or hopefully maybe even an aha moment and maybe one or two practical tips or tools that you can use right away today to help have healthier, more balanced, mutually respectful relationships that are satisfying and effective. And I wish you all the best. And I hope to maybe one day get to meet you in person. Take care.

KATIE LIN: --so much, Carly. Well, welcome everybody to our session. Just a brief reminder that this course is presented solely for information purposes. So the opinions presented here do not necessarily reflect those of the Canadian Medical Association. 

This session is on influencing up. How do we affect change at all levels of training and career stages? I'm Dr. Katie Lin. And along with my co-host Dr. Yan Yu, we'll be taking you through some principles of influence and what it means to influence up. We're also fortunate to be joined by three esteemed guest speakers who bring a rich lived experience to the table. And we look forward to introducing them to you later in this session. 

I'd like to begin with a land acknowledgment. And so we begin by acknowledging the Indigenous peoples of all the lands that we are on today. While we meet today on a virtual platform, I would like to take a moment to acknowledge the importance of the lands, which we all call home, from coast to coast to coast, we acknowledge the ancestral and unceded territory of all the Inuit, Metis, and First Nation people that call this land home. 

And thank you to all of you for taking time out of your busy schedules to join us for today's session. We hope that it'll be useful for you. These are the four key objectives we'd like to equip you with throughout the session. Number one, to understand what constitutes influence, what does that look like in our medical context. Two, to review basic strategies for generating influence. Three, how influencing up specifically differs in terms of its strategies, common mistakes that we can encounter. And four, to understand what influence looks like through case examples and discussions. 

Just a brief introduction so you know what context I'm bringing to this session. I'm a Royal College trained emergency physician from Calgary, working with the Foothills Hospital. I also work as a flight transport physician with STARS air ambulance, and with the Calgary Stroke Program as a stroke physician. So I love brains, and I love medical education. And it's an honor to be part of this session with you. 

I'll let my co-host Dr. Yan Yu introduce himself as well. 

YAN YU: Thanks, Katie. I'm Yan. It's nice to virtually meet everybody. I look forward to chatting with all of you. I am going to be monitoring the chat, too, while folks speak. I have been involved in a lot of influencing up, I guess, events or causes. Let's just put it that way. So this topic is very near and dear to my heart. 

I'll specifically be using the Calgary guide to understanding disease as an example. I founded that. And this is a medical education tool for free online in 2012. And right now, it's used by 3,000 people on average every day around the world. So I'll be talking a little bit about that about the journey. Yeah, I'll hand it back to Katie for this session. 

KATIE LIN: Thank you. For disclosures, other than the honoraria we've received from CMA Joule to prepare and deliver this presentation, we have no other disclosures to share. So as we set out on this journey together, here's just a quick roadmap for the next two hours. We're going to start with introductions to the concept of influence and influencing up and how that applies to us as medical providers at various stages of our careers. 

Next, we have an esteemed panel of presenters who will share their stories of how they've utilized principles of influence to create change in their own organizations and teams. And finally, we'll close with a Q&A panel discussion, where you'll have an opportunity to ask any questions that you might have of our panelists or myself or Dr. Yu. 

Some housekeeping elements, please mute yourselves if you are not actively speaking so that we don't have any audio interruptions. If you are able to, we'd love to have you turn your cameras on to maximize our interactions with you this evening. Being able to see how you're reacting can really help us to tailor the content for you. We'll pause throughout the talk to go over any questions that come up, especially in the chat box, so please do feel free to enter any comments or questions into the chat box as we go and other, Dr. Yu, or myself, or any of the speakers will be keeping an eye on those. 

Also feel free to use the Raise Your Hand feature. And we can call on you to unmute yourself to speak as well during the Q&A sessions. And finally, as Carly mentioned, this session is being recorded and will be available through CMA Joule's YouTube page after the talk. This is the first time we're running this session on influencing up, so if you have any feedback for us please let us know at the end so we can continue to improve this content for you. 

In order to talk about how to influence, we first have to talk about what influence is. And to that end, I'd just like to begin by sharing a story. How many of know who this man is? And if you do please pop it into the chat box. I'll give everybody maybe a couple of seconds here. 

For those of you who don't know him, this is Martin Bromiley. Martin Bromiley is not a doctor. He's a commercial airline pilot. And yet he's had a profound influence on the modern culture of patient safety and medicine. In 2005, Martin's wife, Elaine, underwent what was supposed to be routine elective sinus surgery. Shortly after her anesthetic induction, her airway obstructed and attempts to bag valve mask and place a superlative airway failed. For over 20 minutes, Elaine's oxygen levels were about 40%. And ultimately, she passed away in the ICU of hypoxic brain injury. 

Martin Bromiley insisted on a formal investigation to understand what had happened in his wife's case and how it might be avoided in future. But most importantly, as a commercial airline pilot, Martin insisted that the investigation was focused on the system level failures that prevented a well-equipped, well-trained team from responding in an organized way to the unexpected failed airway case. Martin did not seek to blame individual providers for what happened to his wife but rather to highlight the flaws within the system that needed to be fixed in order to help all future patients avoid the same outcome. 

He basically translated his experiences with commercial aviation's system-focused safety culture into the world of medicine, where it didn't widely exist before. And in so doing, he's influenced our very understanding of patient safety and medicine. Martin and Elaine Bromiley are the reason we now routinely use checklists pre-op, pre-sedation, and pre-intubation. It is the reason we have algorithms in place for high-risk rare events. And so Martin Bromiley is not a doctor, but he has had a profound influence on how generations of doctors have been taught to think about patient safety, including all of us here today. 

Influence is the capacity to have an effect on the character, development, or behavior of someone or something. And the truth is that modern medicine is truly a team sport. We work with various specialties, allied health colleagues to coordinate the complex care needs of patients within a large system. Nothing happens in a vacuum in health care or otherwise. And so we're all connected by that complex network of care. And therefore, our actions and decisions have an impact on those around us, whether directly or indirectly. 

It's important to note that influence is not the same as power. Power is the authority to compel other people's behaviors or perceptions and usually, comes from some sort of hierarchical relationship. Whereas, influence is the ability to alter other people's perceptions and behaviors and encompasses a much broader concept of how we can impact those around us. Influence does not necessarily require or rely on a hierarchical relationship to function, which our speakers will talk to you about later today. 

We've talked about what defines influence, but how do we actually operationalize it? How do we exert influence? Well, the skill of influence requires a combination of interpersonal, communication, presentation, and assertiveness techniques. And like any other skill, it can be practiced to help achieve your goals in your career and your organization. It's important to remember that there is no one way to influence rather it's about reflecting on your own values and strengths and finding your own style to navigate some of those challenging interactions. You'll get to hear about a variety of different influence styles with our speakers. 

And first, let's review the six principles of persuasion. These are fundamental principles of human behavior that are likely to apply in any situation where you need to interact with others in a way that moves them to act. The first is mutual respect or liking. This is where people are more likely to say yes to people they like or respect. 

Factors that can impact liking include physical attractiveness, similarity like shared interests, perspectives, or experiences, genuine praise-- and it's important that it be genuine for it to come across in an effective way and to genuinely create that bond-- and familiarity, so repeat interactions, mutual connections, and association with positive things. The key here is to find common ground to cultivate mutual respect and to like or at least to see the positive in the other person. That's what creates the trust and therefore, the influence. 

Two is reciprocity. So people tend to want to return favors. This is why sales people give us free swag and corporate executives take clients out to fancy lunches. But it doesn't actually have to be monetary to be effective. When my charge nurse and I compliment each other on our awesome new scrubs, we actually feel closer to one another instantly. But this also means that we tend to reciprocate how we're treated. So again, treating others kindly will generally return the favor. 

Three is social proof. This is basically that idea of going with the flow or part of something bigger than ourselves idea. When we see a lot of other people doing something, our brains generally view it as more acceptable, more normal. This can be a good or a bad thing. On the one hand, we can use this principle in a positive way such as normalizing respect for alternative pronouns like they or them for transgender patients. 

This can also be used in a negative way, such as dismissing microaggressions or perpetuating harmful stereotypes. At a change leadership level, it's important to be aware of this principle, because it means that influencing change that aligns well with how things are already being done in your organization is going to be much easier than influencing change that represents a significant departure from how things have always been done. 

Four is consistency. People tend to try and act in ways that are consistent with their earlier words or commitments. For example, if you get someone to commit to participating in a project early on, they're much more likely to continue to follow through on that commitment later, especially if they're reminded of that earlier commitment. And this can be helpful if you're leading a group. But it can also be helpful to resist this psychological urge if you realize that your plate is too full and you need to set some boundaries around your own workload. I think we've probably all been there and are there at present. 

Five is authority. So this one's pretty self self-explanatory and kind of goes back to that power concept. Those in positions of authority generally have more influence over decisions because they can leverage or compel behaviors. But it's important to know that authority doesn't only refer to an official position or title, like program director or department head. 

It can also refer to expertise. So for example, a resident representative on an educational committee is very much the expert on what the resident experience is like. And so has the authority to speak and make suggestions within that sphere of influence. 

And finally, scarcity people feel pressured when opportunity is less available. This is where the salesperson is telling you that the sale is a flash sale only on for a limited time or that's only a limited number of spots left for a particular position. At a change leadership level, this can look like framing an initiative as a select opportunity for a small group of motivated people, and then trying to find ways to reward them for their time at this point. 

And so with that, I'm actually going to be handing it over to Dr. Yu to talk a little bit about how influencing up might look different from influence in general. 

YAN YU: Thanks, Katie. That was awesome. And thank you to Nikita for turning on your video. It's great to see you. And I encourage any other brave souls out there to turn on your cameras. We're a very small group here, just five presenters and 14, 15 attendees. So we're-- this is quite a good group of folks. 

So yes, what does influencing up mean? And how does it compare with influence? Well, from my very layman's terms, non-technical definition, I would define it as just trying to influence or trying to convince somebody of some course of action or way of seeing things from a position of lower or less authority, maybe as a junior member of the medical team. 

But then how do you influence up so? Katie, next slide, please. It really depends on the context in which you're doing so, so I want to preface everything that I'm saying here by saying that the context that I'm going to be presenting here in this section specifically refers to the medical schools, residency programs, academic departments, universities, or within small patient health care teams. And governments or in business, these principles may be similar, but the strategies will be different. 

And this is also based on my own personal experiences. And I'm definitely not a total expert or PhD on this. I definitely have a lot more to learn about this as well. So I do look forward to what our speakers will have to share regarding their influence and their lessons and learnings. 

In general, though, influencing up really presents a unique set of challenges because the six principles of persuasion often fail. So for the first one, mutual respect, where you take time to find common ground, they're busy people. The people you're trying to influence, they're usually in high up leadership positions. And they often don't have time for you to build common ground with them. 

And the second principle, reciprocity. They can do a lot of things themselves. They have teams of people working for them. They don't need you to do them any favors. The third principle, social proof, they are the proof. They are the people who set the rules, who determine how things are done. And often when we're trying to influence up, we're tasked with the difficult challenge of doing things differently compared with how things have been done. And this unfortunately, goes against the social proof concept. 

The fourth principle, consistency. Humans is in generally like to be consistent with what they've done in the past. And senior leaders especially oftentimes like to be consistent with their initial decisions that they've made. And so they tend to resist any sort of proposed changes from underlings. 

Fifth principle, authority. Definitely there are many times when we have absolutely no authority whatsoever. I was the resident rep actually for in residency. And I can definitely recall a time when I was at a meeting and I was speaking with one of the senior management. And they specifically said to me to not annoy them anymore in the course of the meeting itself. And I don't think I was actually presenting anything annoying or close to that. But, yeah, so unfortunately we are at a disadvantage here in terms of authority. 

And the sixth principle here, scarcity. So the scarce resource tends to be money, but it calls could also be time. For the example of the Calgary guide to understanding disease, it was server capacity and the ability to create a website that we can use to share our resource with the world. So there are these difficult things that we encounter when we try to influence up. 

But we try to do the right thing. We still are compelled to actually make these changes that we want. And sometimes-- next slide, please-- it can be a very, very difficult task. And not only because you're not seeing the changes that you feel are necessary, but because it creates a sense of powerlessness in you. 

There's nothing that leads to burnout faster than a sensation of powerlessness when faced with a need. But it's very common for us as early career physicians, as driven, motivated early career physicians to feel that way. But there can be something that can be done about it. And so next slide, please. 

What I discovered when I was doing these influencing of things was first we have to make sure that the cause is the right cause. That it actually would benefit as many people as possible and not just someone's own pet project, for instance. And that means picking battles wisely. And standing up for the wrong cause might not be effective from a societal standpoint. But it may also be a waste of your time and energy. It may also destroy your social capital. 

And the second idea is when you would carry out your influencing up actions. Your timing is critical here. And think about is this something, is this change something that must be done right away, or maybe it might be better to wait for a more opportune time? Don't assume you only have one shot at making the changes that are necessary. If now doesn't work, and even if a few months from now doesn't work, there may be more opportunities to come. 

The third idea is something that I learned from one of my mentors, Dr. Ewan Affleck. Dr. Affleck actually is an Order of Canada recipient. He worked hard for 10 years to organize the entire Northwest Territories EMRs under one single EMR. So that when I'm working up in Fort Smith, the specialists in Yellowknife can actually see everything that I'm doing. 

So when he was talking about influencing up, one idea that he had is, who are you trying to influence? And can they actually make the change happen? Oftentimes, people who you think are in charge and who you think are calling the shots are just stabbing in the dark like the rest of us. Because once the system is set, rarely can individual people in high positions, even if they're in high positions of leadership, rarely can they change things even if they wanted to. So of course, some people may have more control or impact than others. So you've got to be sure that you are talking to the right person. 

Now, when you're sure you've found the right cause, it's at the right time, and you've picked the right people to influence, now you're ready to act. And when you're ready to act, it's important to avoid the common mistakes. And so-- and I know there are another common because I've actually made all of them. I guess they can be uncommon mistakes as well. And I probably would have made them, too. 

But the first one is when I have a cause, I'm very passionate, I'm very committed to that cause. But sometimes, I could also give in to that passion and to give in to that emotion. And so the idea here is no matter how strong your conviction, it's important to keep in mind that the conviction of the person you're trying to influence is equally as strong, if not stronger, and you will not get your way just with passion alone. 

The second concept is fairly self-explanatory. Obviously, respect underlies everything that we have to do as changemakers. The third concept is I put in brackets. And it's actually based on a YouTube video about the above the line or below the line concept, where going above the line means that you always assume positive intent, and going below the line means you're assuming that something that other people are saying or other people are doing have negative intent. So try to always assume positive intent, never assume badly of other people. 

And the fourth is doubting yourself because it turns out that if you behave like an outsider or if you behave like the cause that you're advocating for isn't going to happen, chances are it's not going to happen. It's kind of like the Pygmalion effect that way. 

So all right, so we talked about the common mistakes. What are the actual principles that I've learned to make change happen over time? The first is standing your ground. So basically, when you have a cause that you're sure about, you stand your ground, but you've got to keep the high ground as well. You can agree to disagree politely, but be genuine in your good in your good intention. 

So for me, when I started the Calgary guide, I actually created a survey to survey all my classmates about it to look for the nuggets of good ideas that I know will make the project better, even if it was difficult for me to hear. But there were a couple of other comments, such as one of the comments. It went something along the lines of someday Yan Yu will realize we're not laughing with you, we're laughing at you or something like that. And I really, really have to work hard to actually not let those things affect you, especially when you're trying to work on a cause. And so I was fortunately able to take some nuggets of good ideas out of that survey regardless of comments like those. 

Second concept is just make it about them, do your homework, figure out what they need. And the need can be something that even they didn't realize that they needed. And then give them what they need. And so using the Calgary guide, as an example, we've all been through med school, you've all sat through lectures of lists, lists of signs, symptoms, clinical findings, and none of those lists, at least the ones or few of those lists are rarely if ever explained well at a basic level, at a medical student level that that's sufficient for full comprehension of those topics. And so what the Calgary guide does is it actually translates those lists into flowcharts and, using concise and very simple language, explains the basic pathophysiology underlying the signs and symptoms of disease. 

And so when we gave it to the med school, we gave it to them for free. And this is beneficial to the students, to the lecturers, who now use our slides. And also, it's beneficial for the reputation of the university as well. Because now, this is one example the medical school consistently uses the Calgary guide when promoting the school to candidates during med school interviews. 

Third idea, again, self-explanatory, work your butt off, work harder than everybody else. This is a very thankless task but often necessary. So when I was building the Calgary guide for about a year, I took no no breaks. I was just a hermit. I was working to produce the content. But this is good because it shows that people who are trying to influence that you're being serious and that you're committed over the long term. That's how you get respect. 

And last and perhaps most important, you don't get anywhere with a social change initiative by yourself. You join with like-minded people, the strength in numbers. And working with a Calgary guide folks, and I had a great team, it would not be anywhere where it is now without amazing teams of students and faculty. And there are you and me, medical school, administrative collaborators. We have about 30 or 40 students work on the project every single year. And I've actually found that if you work with others, it can oftentimes correct the many mistakes that I make. 

So that's it for me. I will turn it over to Katie to introduce our brilliant speakers. I hope we're not too behind on time. Thank you. 

KATIE LIN: Sounds great. No, we're doing well on time. And so just as a reminder to wrap up our intro section. None of us get to where we are alone. We rely on those around us to achieve our personal and collective goals. So understanding the role that influence plays and some of the tools available to help us grow the skill can help us be better leaders and advocates of change within our health care systems. 

I don't see any questions in the chat. So I'm going to jump right into introducing our first speaker, Dr. Monty Ghosh. Dr. Monty Ghosh is an internist, disaster medicine, and addiction specialist, who works at the University of Alberta Hospital in Edmonton, as well as the Foothills and Rockyview Hospitals doing addiction medicine in Calgary. 

He works with multiple community-based, not-for-profit organizations to provide support for marginalized populations, such as those experiencing homelessness, substance use, mental health concerns, as well as those who are in corrections. He's an assistant professor at both the University of Alberta and the University of Calgary and is heavily involved with provincial policy building in Alberta as well as with research. He was as CMA-- sorry-- Young Leader's Early Career Award winner in 2021, wears many, many hats. And I'm very excited to have him speak with us today. Handing over to you. 

MONTY GHOSH: Thank you so much, Katie. I really do appreciate it. And let me try and see if I can share my screen here. Again, thank you so much for having me here. As part of the discussion, if anybody has questions to jump in and ask those questions. 

I really liked both what Katie and-- all of a sudden, my screen is not working right now. Hold on a second here. Can you see my screen? Is it working? 

- We can see keep calm and hack the system. 

KATIE LIN: Yeah, that's what I'm seeing as well. 

MONTY GHOSH: For some reason, it's not showing up on me. Let me stop sharing for quick sec and then try to share again. 

I think we just saw your starting out slides. 

MONTY GHOSH: OK, and I can see it now. So we're perfect. So yeah, no, first of all, thank you Katie and Yan for doing the introduction. There's a lot of nuggets that I learned off of you guys right now as well. So I really do appreciate that. 

So yeah, my presentation is basically like keep calm and hack the system. And I think that's very much what I've tried to do with the last few while. I've had to sort of struggle with influencing. And I've learned a lot. And one of my mentors told me that when there's a will, there's a way, and you got to hack the system. And for those of you in Calgary, that's Martin LaBrie. He's been a huge mentor to me. And that was his big thing that he kept sharing with myself. 

So just a bit about me. When I first moved to Calgary from Edmonton, and I work in both cities and I would do internal medicine U of A Hospital in Edmonton. But initially, I moved to Calgary because my father was sick. And I had sort of a fresh start in Calgary, so to speak, didn't really know anybody, didn't know who to work with or where to work, didn't have a job when I first showed up as well to the city. And just kind of just started working in the community. 

And it was tough. It wasn't easy. I had to move to Calgary because my father was sick. I had to be close to him. He was going through chemo at the time. And so it was a rough ride. But at the same time, when you start off and you just graduate and you don't have any existing jobs, like what do you do with yourself? How do you how do you reach where you want to reach in your career and do what you want to do? 

The first job I found was actually the inner city and was the Alex Community Health center. And I started working with them. And I remember starting off feeling a lot of shame. And the shame I felt, I think, was because I felt that I didn't have a glamorous job at a hospital. I didn't have a university appointment. I had no influence. I had no power. And I felt like there was things that I wanted to do but had no access to. 

A lot of things that, when I was working on this, I realized that there was needs. But I felt like I didn't have the ability to make changes just because you needed to have an academic appointment to make those changes. If you want to write grants and get money for research, you have to have the ability to be a part of the university. And if you don't have a university appointment, there's nowhere-- no way to start, or so I thought. 

I also didn't really understand the bureaucracy of the health authority of the university, the social services system. But again, talking to certain people, the one thing that I learned is that there's always workarounds. And there's a way to sort of hack the system and get to where you want to be and get to make the change you want to make without having those structures necessarily and without being in with those structures as well. 

And one thing that I've also learned through leadership is this slide, and I got this from Leonard Marcus and Eric McNulty, two of my teachers in the past, when I did my MPH. And they always talked about leadership being in all directions and always taught leadership as leading down. You have to sort of lead down, you lead others. 

But what they taught me was that you lead not only across your own organization, but you also lead beyond your organization, to other organizations. You can also lead up as well to people who are in authority, figures of authority, people who are your bosses, people who are leaders and have positions of authority. You can lead up to them as well. And that you shouldn't feel shame in doing so. You shouldn't feel shy about doing it. You shouldn't feel scared about doing it. And in fact, many leaders do appreciate that, too. 

So when I think of influence, I think of positive change and in trying to make positive change. And that is always tricky to do. And also, when I think of influence, I think about how do we make things happen, how do we make that change happen. And so I've got two stories to share. 

When I first started, there were several things I wanted to do. There was a few projects I want to get off the ground that I felt that were big needs in our community. When I worked with the Alex with people who are experiencing homelessness, I realized that often they would get discharged from hospital and they would just get kind of dumped at our shelter sites. And we didn't know what to do with them. 

And they were pretty sick. They definitely should have still stayed in hospital. But when you look at the hospital angle, that they would see that as being the exact opposite. We'd be like, hey, you know what, they don't need to be in the hospital. They could just go home and get some bed rest. And so for example, if we had appendicitis, we would go to the hospital, maybe get an appendectomy or be put on antibiotics, spend a couple of days there, then told to go home without bed rest-- sorry-- for bed rest and not show up to work. And that's easy for us to do. 

But if you're experiencing homelessness, you have no bed to go to. You have no place to end up in. And so one of the big programs that I was trying to get launched in at the time was a medical respite program that you guys have in Ontario. And that was at one of our shelters where people could go to, as opposed sort of discharge space or even pre-hospital state space, to get rest and to recover and recuperate. 

So that was one of the big projects I was trying to get off the ground. But I wasn't sure how to do that. And I had a few other projects about navigating people out of the health care system. But I had a few, again, a few projects that had in the fire at all times. And then I think that really helped ultimately to build connections and connectivity with others and others who believed in yourself. Because as Yan mentioned, you want to be able to-- you can't do things Alone, You have to do things with a team. And by doing things in a team, you actually gets to where you want to be. 

So the first sort of story I wanted to share, which is one of the rods that I had in the iron is the NORS slides. This is the National Overdose Response Service. So when I was in Calgary, again I was sort of struggling, and I started to do some addiction medicine stuff before I went to the formal training for that. And I was chatting with a patient. And one of her biggest issues that we're having in Calgary is that a lot of people are using alone, almost 70% of people who are overdosing or overdosing in their own homes by themselves. 

And I was just chatting with a patient of mine who was living in Grand Prairie. And I asked him he had a Naloxone kit and if he was using it alone or not. He said kind of using alone, kind of wasn't. I'm like, well, what do you mean? And he was like, well, I was FaceTiming my buddy in Edmonton and we're using together. I was like, well, if one of you overdoses, what happens then? He's like, well, we have each other's addresses. It'll be easy for us to dispatch EMS services, somebody just call 911. 

And it was just such a brilliant idea. And just because of the stigma of addiction, he ended up not wanting to drive the idea forward. He was really content with living his life with his wife and his kids and he didn't want them to know the substance use. But again a brilliant idea that I was like, this could be one way we can mitigate the crisis that we're facing with drug poisonings. 

So in Alberta, in Calgary specifically, I was trying to get this idea off the ground. I remember writing up a one-pager and going from place to place to place trying to pitch the idea. I showed up at the Distress Center in Calgary. And they didn't like the idea. They wouldn't even open the door for me. 

I remember trying to call the Kids Help Phone. I remember trying to pitch the idea to AHS. And it was really hard to get it off the ground. I did look out. This was, I guess, where circumstance kind of comes into play. But I had a chance meeting with an individual at a charity event who really took a liking to the idea as well. 

And the only reason I was at the charity event was because I had all these other projects in the fire, I should say, going out at the same time. So I got invited to another charity event, and he was there. And he asked me what I was up to. I think Rita knows him, Doctor Mike True. And he was like, he asked me where my ideas were, and I shared it with him. And he as a mentor was like, why don't I work on this with you? 

I would really attribute a lot of what I learned from leadership because of him. He really inspired me. He liked the idea enough that he helped me with my grants. He helped connect me with certain groups of people and try to get the project off the ground. We eventually did get a $1 million grant from Alberta Health Services to get this off the ground. And then calamity struck and the government at the time did not like the idea. And so they shut it down 8 hours before launch. 

So we're about to launch in Calgary and 8 hours, we got shut down by the government of Alberta. It was pretty heavy hit because the government was like, you can't do this. You can't create a phone line where people can call and use drugs. 

So that didn't work out. But then going back to some of the principles that we talked about, when you really are passionate about a project and even though your hands are tied, there's other ways to work around it and hack the system. And no one in AHS or UC or UA would have wanted to touch the program. They were like, we don't want to get the government mad. We don't want to agitate them. So we cannot help you. 

I remember speaking to Ethics, speaking to the Dean. And I'm like, can you help me? And there was like a big no. But again when there's a will, there's a way. And so leading across kind of came up. And so there was a group in Vancouver and a group in Hamilton, Ontario, who were actually doing something similar. 

One was creating an app around this. The other group had a phone line two years down the road as a nonprofit that were functioning in Hamilton and very similar concept. And so we allied ourselves together, and we tried to make a large pitch. And I remember trying to track down people in Health Canada, pitch the idea to them, do cold calls and cold emails. 

And eventually we were able to reach someone who was willing to listen. And they heard the idea. They granted us a larger audience with all the stakeholders. So we pitched the idea, then they sent us a document and they're like, no this is a grant template. Right it's a grant, and we'll see what we can do. And it took some time, but we were able to get a $2 million grant to launch the program. And we're now nationwide. 

We've had 91 overdoses, 4,500 phone calls, no deaths surprisingly. People all across Canada have been using the line. And we encourage them to use alone. And I think the thing that I wanted to bring across is that, just always keep going at what you want to do and take things one step at a time. And even if you fall down that hill that you're trying to climb up, try again and don't give up. 

The second story that I wanted to share was during the COVID crisis. And I think this is really a perfect example of leading across and up as well. I have this little quote here because there's another quote that Mike told me. He was like, if just take one thing step one step at a time and before you know it, you'll be halfway up that mountain. And you look behind you you're like, how did I get that far? 

And it's a quote I've always lived because every time I was trying to get something off the ground, I felt like I wasn't getting anywhere. And then you just look behind and you you're like, wow, I've made it so far ahead. How did I get here, and how did I make it to this point? 

So during the COVID pandemic, the very early stages back in March 2020 when things were not going as well, we didn't really know what we were dealing with, we realized that there was a situation with isolating individuals who are experiencing homelessness in our city. And no one was doing anything about it, for the homeless population, that is. 

We knew that there was people who were working in the hospitals, people who are focused in long-term care facilities and giving guidelines or guidance around what to do, or how to manage the pandemic with people who are living in homes. But within the shelter system itself, there was nothing happening. And we knew that because we keep reaching out to public health authorities, asking what's going on and there is no response because they have their hands full. That was the bottom line. There was a lot of people who are really, really busy. No one knew what was going on. 

And so a group of us, about two to three of us who are physicians, decided that we're just going to do something and just get something started. So we literally got together, put some pen to paper, stay up to 4 o'clock in the morning to plan out screening isolation services and try to put up a proposal to get a hotel up and running in Calgary in the beginning of March. 

And we didn't know if we had the ability to do that. We didn't feel like we had the authority. No one gave us the authority. We had no positions to make that happen. But we decided to do that. And so part of this was leading across within our own organization, so getting the Alex on board, getting my colleagues at cups on board. And then was also leading beyond to other organizations. So talk to the Calgary drop-in center, talk to all the other shelter sites. Talking to the city of Calgary. 

The one thing that I learned from the situation is how to lead up as well, because we were by ourselves. We weren't really sure what to do. We just started doing. And I think that was a very important lesson is that you shouldn't-- first, don't work alone but if you don't know where to start, just start somewhere, just start doing it. Don't think twice, just get started. 

And before you know it, AHS was coming to us asking us what we're up to and what's happening. And then we had the government call me. We had the ministries start calling. And our chief medical officer of health calling asking, what are you guys doing? What are you guys up to and how can we help? 

And so before we knew it, we had, I think a three-week time span, the hotel set up in Calgary Zone. And then all of a sudden we were able to help with that Edmonton Zone. And then we were able to help with Grand Prairie, and Fort McMurray and different parts of Alberta to get these things up and running. 

And by leading up, it was all about having conversations, having pen to paper, showing them what you're planning to do, telling them that this will work because your population, being confident in what you know, and being very forthcoming with what your plans are. 

I'm trying to look at the time. I don't know how much more time I have. I think I only got 2 more minutes. So some advice to new physicians. Things that I learned was that influence and power are two separate concepts as was mentioned by Katie earlier. I always thought that you need to be in a position of power to create influence, and you don't. And actually influence lasts longer than power. 

People come and go from positions, but the influence that you make, connections that you make last a lifetime. So that was the one thing that I learned from this pandemic, from NORS is that the connections that I made with all the homelessness sector in Calgary really helps out when we ran into situations. 

Those connections helped carry forward ideas, helped solidify ideas, and helped influence the government in listening to your ideas because they're like, wow, the whole community is behind you. They believe in what you're doing. They're supporting you. We should listen to this person. And influence comes from not just above, but it can happen across spectrum services as well. 

It takes a village. You can't do this alone everyone. Every project that was successful was always been a collaborative with others. I can't take credit for everything because it wasn't just me. We all did this together in unison. 

And then also be a team player first before becoming a leader. One of the big lessons I learned from others is that for those who just decided to do without doing collaboration, things failed miserably. You have to do it in collaboration with others. You have to do it as a team. You have to listen to others. Even though you think their idea might not be useful, there's things you learn by actually trying it out. 

It's keeping your own ego in check. And that's the thing that I've learned the most. Those are my big pieces of advice is that, these are the four pieces of advice. Never give up. Just keep trying to do what you want to do, what you believe in. 

What you feel, as Yan had mentioned, is not just for yourself, it's for everyone else. You're doing this for the community. You're doing this for others. That's so much more powerful than doing something for yourself, and that's what drives your passion, I believe, for most of us. Yeah, that's sort of my story. 

SPEAKER 1: Thanks for your words of wisdom, Dr. Ghosh. I will say from an emerging perspective, just a massive thank you for you and your team for the vision and the tenaciousness to get this across because truly I'm not sure what we would have done through the pandemic without the Ace Hotels. It was an absolute game changer, so Bravo. 

If anyone has any questions, you can feel free to pop them either in the chat box or you can even raise your hand feature and unmute yourself and ask. I'll give everyone a couple of moments here to ask Dr. Ghosh any questions. And if not, we also do have our Q&A session at the very end for our speakers as well. 

So seeing no questions or hands for right now, I'd like to just introduce our next speaker, Dr. Rita Watterson. Dr. Watterson is a general adult psychiatrist in Calgary. She provides both inpatient and outpatient psychiatric care to the city. And she received Calgary's Avenue Magazine's Top 40 Under 40 Award in 2018 for her work to advance mental health care in Tanzania with the organization, Kolabo. And so I'll hand it over to you Dr. Watterson. 

RITA WATTERSON: Awesome. Thank you so much, Katie. It's a pleasure to be here. And it's been so lovely hearing the words of wisdom from yourself and Yan and hearing Monty's story. So thank you so much. 

As Katie was saying, I'm primarily an in-patient psychiatrist. I'm coming into my fifth year of practice. I also work at a number of different outpatient settings. So I worked at an adult psychosis clinic. I'm the psychiatrist at the refugee clinic. I run part of the day hospital service. I'm involved in PGME, work in emerg. And then the side hustle is this Kolabo project. And so that's primarily what I'll speak to today. 

When I think about this influencing up idea, it really applied to starting Kolabo because Kolabo was started in my first year of residency in 2013. And so a lot of the principles that Yan brought up, I think I'll speak a little bit today because I think those are things that really had to be utilized during those initial years to gain momentum and move the project forward. 

So Kolabo is a project that's primarily based in Mwanza, Tanzania. And Mwanza is actually a city about the same size as Calgary. And they have one primary hospital there. And when I went in 2013, I was in my first year of psychiatry residency and I went there for a month with a fellow colleague just to see what was happening on the ground. 

At that point, they had one psychiatrist covering an inpatient ward of 50 patients, a CL service, an outpatient ward, and clinics that would have 100 to 200 patients in a clinic as well as community clinics. It's a catchment area of 10 million people. And so that psychiatrist there was very overburdened and drowning in work. And so she is trying to find solutions for her community in her department of how to make change and how to be sustainable and how to build medical education. 

And so I come from a background. I did an MPH prior to medical school. I focused on global health during that time and had a global health focus during my medical school, but couldn't find a project that really aligned with what I wanted to be my skills and my knowledge and something that could be community driven and have a real longitudinal relationship. I think global health works should be based around those principles. 

And so when I was there, we started to kind of have some meaningful discussion around what that might look like. We were very lucky in terms of circumstances at the University of Calgary. I had a long standing relationship with that university [INAUDIBLE] And so those relationships and partnerships were already in place to start to build something meaningful. 

And so with that in mind, I came back and a very close colleague of mine, Kimberly Williams and I started to think about what this would look like in practice. And we wanted to start to build a partnership that our residents and our department and our PGME program could really be part and parcel of. 

And so that needed a lot of thinking in terms of how we were going to influence and shape the thinking of the department, of our staff, or our PGME leaders about why we would want to invest in a program in Mwanza, Tanzania, and what benefit that would have, frankly, for our department and for our residents and for our learning that would be mutually beneficial for them moving forward. 

So I'll speak to that process in a second. The goal moving forward what has happened is that now this program has a staff of five, which I know sounds very small still. But comparatively to one psychiatrist, it's quite significant as we've been able to fund three scholarships to provide residency programs for subsequent staff. 

We've been able to go from having no UME curriculum within that university to them collaborating to make a UME curriculum and now handing over that entirety of the UME curriculum. And so 250 medical students go through that program a year. And now that's going to be entirely taught by their program. 

And then in 2023, they're actually going to start their own PGME program. And so in Tanzania, there's only one program in the major city. And our trainees have actually gone to Uganda and Kenya to do their training because there hasn't been appropriate training within the country. So it's going to be a huge next step for us to help collaborate and make a residency program. 

So moving back to thinking about 2013, 2014, what we're able to do because the barriers at that time were really significant and thinking about how we're going to shift the perception of our colleagues in Calgary around why we needed to join this program. So one of the ways that we did that, and I think that's really important, is building the fund of knowledge to present to these stakeholders. 

And so we got funding to do an initial needs assessment and went back a second time with a bigger team to conduct interviews, to do questionnaires, to meet with all the stakeholders within Tanzania around what a project could look like, what they need, what they want, what they want to get out of it. And that was then compiled into quite a significant report that we were able to hold on to and present to those people in leadership positions. 

And so I think you need to think about the data that you rest on, and especially when you're potentially a resident or early in our career. We want to be able to know that background to give our rationale as to why we're doing what we're doing. And I think for us that needs assessment was able to capture that piece. 

I think the second piece that we did quite well as we brought in a number of key stakeholders. And so as we were early residents, we needed to find staff that were keen in this area and able to give their own time and service to something like this, but also had a fair degree of authority and clout within the department so that when they were able to put their name behind this and it would be able to carry weight. 

And so I think for us that came with a number of, lots of different conversations, just like trying to seek out staff to be able to latch onto the collaborative project. And we were very lucky early on as to who wanted to be engaged with the project. But it meant after residency teaching, like someone mentions global help, we're there at them having that conversation about why they need to be involved in Tanzania. 

Or if we catch someone in an elevator and they say they're interested in traveling abroad, we would start talking about the project with them. So any time we had that opportunity to bring key staff in, we would do that just because we know that it would really allow us to gain a lot of momentum there. 

I think the other piece that was really key for us being able to gain momentum and make those changes in terms of moving the project forward was finding who the change makers were in the number of departments that we worked in and getting those change makers who thought really innovatively, who could understand the concepts that we were talking about at the table so they could think about, from a higher level, how they would want to move this project forward. 

And so we were very lucky at that time that our head of department psychiatry was very like minded. And she grasped on to that project, and we really always ensured that we kept her up to date and knowledgeable about what Kolabo was doing so that those change makers were really involved. 

And then another barrier, I think, that we found, I think a lot of projects find, is those financial barriers. Especially for a project that's based overseas, I think it can be really challenging to find funding for that. And I think you just have to become really innovative and be willing to really do the hard work. I think Monty was speaking to that, making that step by step change. 

And so if we had to run fundraisers ourselves, we were doing all that kind of stuff at the forefront. We were sending out lots of different emails to anyone who was willing to fund these sorts of things. We were reaching across departments. We're trying to find support. And so I just think in that way we're trying to be creative as to how we found funding, but also realizing we might have to do a lot of heavy lifting ourselves. 

When I think about those principles that Yan was talking about and then Katie, you talked about too, I think there was a lot of things that we leveraged in terms of being able to influence up and move the Kolabo project forward. So, for example, that concept of reciprocity. 

So we were able to do that because we were able to demonstrate that the PGME program in Calgary didn't meet the needs of vulnerable populations and global health. They're learning about those objectives. And actually that there was a bit of a scarcity and deficit in that area. And so by being able to demonstrate that we would be able to fill that gap by having residents involved, then I think that made it much easier for the department to bring on this project. 

Dozens of residents have been involved in Kolabo. We have a chief resident of Kolabo. And we actually try to make it quite resident-driven, so they're able to take on these leadership positions. And that has been seen as quite a benefit because it's been able to fill the gap of the PGME program in providing that training. And so therefore, it makes it much easier to pitch funding and time away and all these different sorts of pieces. 

As well, like that piece around scarcity, Kolabo is now one of a few projects across Canada that's able to provide this training within psychiatry. And demonstrating that is important because it actually draws a lot of residents in. And CaRMS it's a thing that's pitched for us in Calgary. And so that's another reason to be able to get people hooked into the project and get our department on board. 

I think as well we really tried with the key stakeholders to build mutual respect because we had not only those kind of key stakeholders, a number of psychiatrists and leaders, but also recognizing that both Kim and myself in those early years, we had a lot of experience within this field. And we could bring that knowledge and background to it. And so I think there was a degree of mutual respect that we were able to leverage as we moved this project forward. 

So when I think about the key learning points that I've been able to take away from being involved in Kolabo as it's grown and gotten bigger over these years, one thing I think about is the importance of preparation. And so when you're thinking about meeting with stakeholders, leaders, department heads, whatever that may be, really important, , as a psychiatrist I think about our DVT and CBT skills. 

And so one thing you can do is think about your scripts for what kind of difficult conversations are going to look like. Maybe talk them through with a colleague. Maybe write them down. Play it forward. Think about if it's going to go this way, that way, work out all the different scenarios so that you're able to talk through some of those things. And I know for me, personally, that was a skill that really was quite helpful. So that when I did have some difficult conversations, it allowed me to stay quite regulated and on point. 

As well hearing Yan talk about some of the really challenging feedback that you can get as you move projects forward, I think it's important to really build a network of trusted allies and people that you really care about their opinions or feedback is really important to you. And that you have that really strong relationship built on trust. 

And then the other voice is, let them fade into the background. Don't let that other stuff get in your forefront because otherwise, you won't be able to move the project forward like you would like to. And I certainly like in moving forward a global health project that a lot of people ask a question, why do that in the first place? I think you've got to be very wary of those unhelpful voices and where we go to really park those in the background. 

And then I think as early staff, as residents, you just got to trust your experience and knowledge. You have a lot that you already have. You can demonstrate that through that there's a lot more common ground than you probably imagine there is. And so trust a little bit of that intuition there. 

Lastly, I think the points around advice to give moving forward. So I'm now five years out. This is a little bit of a more challenging time because there's a lot of different balls I have to juggle at times. My work, my side hustle, family, all these obligations are balls in the air. And when I think about that, what comes to mind is the importance of value-driven work. 

So you really should be managing your time and thinking about your time about what is important, like what makes you happy, what gives you meaning, what gives you pleasure. And your time should be directed to those things. And so for me, it was very clear early on in medical school and residency that I wanted to be involved in something like this. 

And so for me, that makes it very easy to designate time to a project like this. And so just thinking about that it's important that your work because you're going to be pulled in so many different directions and asked to do a billion different things that it really be value-driven in a lot of ways. 

I think as well I've pushed myself to think about a growth mindset rather than focusing on the deficits that I carry and focusing on the fumbles and the difficult challenges and instead thinking about when I have setbacks, when we have a team has setbacks, when Kolabo setbacks, how can we grow and learn from these opportunities? Because I think if you can shift yourself to that growth mindset, then you're really going to be able to build a lot of momentum and learn from things that have gone wrong. 

And so I personally try to really recognize my blind spots and the distortions that come up for me and being able to do that and recognize that stuff and then just being able to grow, I think has been pretty effective. So I think that's probably all I was thinking about covering during that time. So maybe I'll hand it back to you there Katie. 

SPEAKER 2: Actually, Dr. Watterson I'll be thanking you. So again, this is amazing work. I actually realized I'd heard about Kolabo through the work of some of my friends who are in psychiatry. So that's fantastic. And thank you for giving us your advice and lessons that you've learned along the way, the importance of preparation, finding a group of trusted advisors, and letting detractors fall to the background, spending time in a values-based manner, having a growth mindset. Those are definitely lessons that I and I'm sure many others will find useful as well. 

So I just want to take the opportunity to let our attendees digest all the wisdom that has come our way. And if anybody has any questions or follow up in the chat, now's your chance to pop them in. And just looking at chat, definitely, yes, this is our first influencing obsession. If you can please give us feedback on how we're doing, we'd love to hear from you. And the link is in the chat as well. 

Nikita, you're welcome. Thank you for turning on your camera so at least I can see if I'm confusing you or not because my speech is not as eloquent as Katie's. Stephanie has a question. By the way, Stephanie it's good to see you here in this group. Stephanie and I work together as part of the CMA, practice management curriculum here. 

How do you balance your side hustles with your financial wellness, assuming that you're not making much from doing these side hustles in the beginning? So that question I think goes out to Dr. Watterson, but if Dr. Ghosh has any insights or if Dr. Damji as well, feel free to answer. So Dr. Watterson would you like to take that? 

RITA WATTERSON: Yeah. Stephanie, I think that's a great question, and I'm glad you bring it up. I think all of us are doing some degree of side hustle or some degree of work that's underpaid or not paid. And I think you just need to think about the juggle and how much you're willing to take on the side hustle versus how much where your values lie in terms of what you want to be doing for the majority of your work and where you ultimately want your income to land. 

And so I think I've learned that Kolabo can't take up all my time. I can't make $0. But it can take up 10 hours a week or 5 hours a week on these weeks. I think I really ensure that I'm very mindful of how much time it takes up. And simultaneously, I think I'm also very mindful about what other work I pick up that does bring income and what kind of income it's bringing and does that balance out the objectives and values that I'm trying to kind of continue to bring. Does that answer your question Stephanie? 

STEPHANIE ZHOU: Yes, it does answer my question. Thank you. 

RITA WATTERSON: OK. I wonder what others think of that. 

MONTY GHOSH: That's the part that I struggle with the most as well, is do you spend time doing this and at what cost because I could easily make more money by working more hours instead of going into meetings around the things that you're working on. But it comes to what you're willing to sacrifice and what your passion is. At least, that's for me. And I love the project so much. I feel like I'm making a difference. I love the people I work with that I'm willing to take a hit. 

The alternative would be doing an ARP in the future. And so if you're really into this kind of world juggling, administration, research, innovation, applying for an ARP would be very helpful. If you're ever doing innovation, try to make sure there's a research tilt to it, which would be beneficial for your ARP as opposed to just program implementation. But, yeah, I think that would be sort of a way to sort of mitigate that and work around that and marry the two. And that's what a lot of my colleagues have done. 

An ARP for you, Ontario people that's the alternative reimbursement. So it's a salary basically from the university or from an academic center. And it doesn't necessarily need to be from an academic center. The thought process is that you need to have one from Alberta Health Services, for example, our health authority or the academic center. But there's lots of not-for-profit agencies that offer ARPs as well. So definitely look into that if you can. But yeah, that is an option to help mitigate loss of income to do what you want to do. 

ALI DAMJI: I think the only thing I would maybe add to that as well is that sometimes when you're initially trying to get something off of the ground depending on what it is, there is likely a large component of work that you're putting in that's unpaid. But that doesn't mean that's going to be the case for the long term. So sometimes your innovation or your initiative that you're doing may eventually lead to something that could be funded by your funder or it could be funded by your institution, your hospital, your university, and you might be able to eventually get some remuneration back as well for the work that you do. 

So I know that was the case for me, and I'm going to talk a bit about that in my remarks around the assessment centers and some of the work that I had done there. So that was the one thing too that I noticed in that journey, was that eventually it started off as being entirely unpaid but eventually did transition into something that was paid. 

SPEAKER 2: Thanks Dr. Damji and thanks Dr. Watterson, Gosh for your answers. And I hope that is a good thorough set of answers for you Stephanie. Thanks for your question. And with that, that's a good segue onto our last speaker Dr. Ali Damji. So Dr. Damji, full disclosure, a great friend of mine. I'm very excited to be introducing him. 

Dr. Ali Damji is an academic family physician, an addiction medicine physician. He's also the COVID-19 medical director and QI program director at the Credit Valley Family Health Team and Family Medicine Teaching Unit, and Halton and Mississauga Rapid Access to an Addiction Medicine Clinic. 

He's also an assistant professor in the Department of Family and Community Medicine at the University of Toronto. So he's bravely joining us from Ontario tonight where it's past 10:00 PM. And also serves as the division head, Primary Care at Trillium Health Partners and was the former physician lead for THP's COVID-19 assessment centers. 

Dr. Damji and I were actually in the College of Family Physicians of Canada's section of residents together back in the day. And I've actually seen him put his considerable influencing of talents to work multiple times to great success. So I'm super excited to hear what he has to say. And with that, I'll turn it over to you Ali. 

ALI DAMJI: Thanks so much for the kind introduction Yan. And I'm so honored to be here with all of these panelists and wonderful people, and also to be part of your panel today as your friend. So thank you so much for that. I'm just going to quickly share my screen here. 

And so just to add a little bit to Yan's very, very kind introduction, to give a little bit of context for myself as well. So in terms of where I am in my clinical journey, I'm in my third year of independent practice. So I finished residency in 2019, and I'm now just about to enter my fourth year of practice with a balance between addiction medicine and my family practice as well and medical education, quality and innovation, and health system leadership being really important aspects of the work that I do. 

I am fortunate as well too that I do work in almost like ARP type model. For us, it's a family health organization model for people that are from Ontario. So it's almost like a salaried type model in an academic unit. So that's been very helpful in terms of being able to participate in these types of initiatives that I've gotten involved in. 

And so in terms of whenever I give talks or when I tell people that I'm currently now the division head of primary care for our hospital. And Trillium Health Partners is one of the largest community hospitals in Canada. And as division head, I'm responsible now for all of our family physicians, functioning as their chief and their director. 

There are many times where I have a lot of imposter syndrome, especially being three years out and having this role and having to do these different things. And so I often ask myself, how did this happen, and how did this journey unfold the way that it did? And I think that influencing up has certainly been a large part of it. 

I think that I've been fortunate in terms of building connections and working with really incredible people that have mentored and supported me to get where I am today. And so I'm going to be sharing a little bit about that journey and also some highs and lows in terms of that particular journey and what I learned from that. 

And so this is an example of a low. So those of you who may know me from Ontario and my history as a medical student may have found out about that story. And maybe even those of you from out west may have heard about this story because it was so prolific when it happened. So this is essentially a snapshot of something that happened to me when I was in my fourth year of medical school. 

I was one of the co-presidents of the Ontario Medical Students Association. And at that particular time, it was a very controversial time in Ontario in 2016, 2017 where there was a controversial tentative physician services agreement, a lot of disagreement in the profession at the time, a lot of conflict. And then there was also a big governance renewal that happened within the Ontario Medical Association in the aftermath of that particular vote. 

And so as the president of the Ontario Medical Students Association at the time, we decided as a board to endorse that particular physician services agreement and that put us in opposition with members of the physician community, who got quite upset with us about it. And so as you can see, eventually these things escalated to the point of actually turning into threats and personal attacks. And at one point, I essentially was having CaRMS match threatened by individuals who are quite upset with the stance that I was taking on behalf of the students and the leaders that I was working with. 

And so as you can imagine, this is kind of the classic example of being in a position relatively without power. And I think many of the residents here may relate to this in terms of when you're faced with a situation like this that's clearly wrong, you want to make an impact, you want to make a difference, but you feel like any move that you make could essentially end your career or puts you in a really compromised position. 

And so this was a really, really early lesson for me in terms of the power of influencing up and how to do that effectively in a way that would able to allow me to still save my career and actually enhance it and turn the situation into something positive and an opportunity to advocate against bullying in our profession. And so I'm going to talk about that shortly. But I just wanted to kind of set the stage a little bit with that one. 

In terms of what I think influence is, to me, I feel like it's that ability to move people, move their ideas and your organizations and community and even an issue itself. And like we were talking about earlier, it's not about compelling people, but it's about altering people's perceptions so that they may be able to see your point of view. And I think that the important thing about influence as well is that it's something that we can build over time. And so I found that I started off in that particular position as not being particularly influential in the space. But over time, I was able to build that influence because of several key principles. 

So going back into these stories, advocating against bullying as a medical student, what essentially happened in that particular scenario is after these messages started coming in and it started to feel quite real as a fourth year medical student that this could potentially cause harm my career is that, I tried to make sure I got the support that I needed. So I reached out to mentors. I reached out to different levels that I could, whether it was within my university and beyond that as well. 

And one of the reflections I had as a student leader at the time was how privileged I was because of the fact that I had those connections, and I had the ability because of a leader to actually access those people. And one of the things that horrified me when I spoke with some of my colleagues at my home university. 

And when I spoke with some of the leadership there was that they told me that this particular incident that had happened to me was something that they see relatively commonly and that it's not a one-off occurrence that this had happened, but actually something that they had a process and procedure for because of how commonly these things happen in medical education. 

And to say the least, I was quite disgusted when I heard that because of the fact that this could be happening to my colleagues all around me who very well could be suffering in silence, terrified before match day around, being threatened by their preceptors. And there are being really little conversation about it and that this being accepted as the status quo. 

And so for me as a leader, I felt that it was important for me to try and influence up. And while I was in a position of relatively lower influence, yes, I was a student leader but at the same time working in an institution that was already coming down on me and seeing that quite firsthand. At the same time, I felt that I had a duty to try and make this better and try and use my experience and what I had learned to make a difference for my colleagues. 

And so what I did in that situation is I really tried to galvanize support and create a vision around this. And one of the biggest things when you're thinking about influencing up is figuring out what your why is, figuring out what it is that you're passionate about. And I know my colleagues have spoken about values and that's a very, very important place to start. And to me that value in this scenario was the fact that it just simply wasn't right that our medical students and trainees could be bullied and intimidated like this and that could be seen as something that's OK. 

When we think about some of the earlier comments made as well by our hosts, when we think about the sustainability of our health care system, it's also a health systems issue because we know that if medical students are bullied, they are then going to turn out to be bullies when they come into practice. And it just perpetuates the cycle. And when you think about reporting of errors, when you think about when things go wrong and conflict, all of these things are exacerbated by the culture of harassment and intimidation. 

And we know that a safe health care system cannot function if there is bullying and intimidation occurring in that environment. We know that that's going to lead to harm to our patients and to our colleagues. And so when I was coming up with my why and my vision, it was really important that I emphasize those points as well because as my colleague said, we needed to make it about the broader group. It couldn't just be a medical student issue. It had to be about the broader system as a whole. 

And what I found was that when I did that, it brought people in. And it brought people in that you would expect but at the same time, it also brought in some unexpected voices as well. So we saw our regulatory colleges got involved. And they wanted to help, support the work that I was doing around advocating for this. We saw the medical institutions and the medical schools all rallied around this as well. 

We saw professional associations, including the CMA actually that stood for creating a code of ethics and incorporating civility into that particular code. And I got invited to actually contribute into that work. We saw the Royal College and the College of Family Physicians of Canada inviting me as a speaker to try and actually elevate this platform and this dialogue as well to be able to share what was going on with our leaders across the sector. 

And so when you create a vision like that, what I realized is that when you make a really big encompassing vision that's about the future of the health care system, you can then start to attract partners too. And I found that was extremely important during this particular low time to be able to do that. And for me personally to know that all of these institutions and organizations were interested in my story and also wanting to make sure that it didn't happen to anyone else ever again, that was huge for me in terms of making myself feel a bit more confident as I got towards match day. 

In terms of some other things that I learned from that, I also realized that influence really can snowball. And so those conversations that you have with one-off people, whether it was a mentor who I just trusted as a colleague that I could open upto to the registrar of the CPSO, I found that influence continually snowballs. 

And so one of the things I always encourage people to do is to be open, have conversations. If someone wants to meet with you, even if you don't think it's really relevant, just meet with them. Because even if it's not relevant at all, you'll still make a really amazing connection. And they may know people that actually are more relevant and will help open doors for you. And so one of the things that I learned as well in that experience was that there was no one who was irrelevant in the story. We were all part of it, and that I was open to meeting with all of those different people. 

And then I found to that also helped with getting the story to an even broader audience. So at some points, the story even made it to the public. And we were able to put out news articles and other pieces around the fact that bullying in medicine was unacceptable. And again, that wouldn't have happened if we hadn't reached out and if we hadn't tried to make this a bigger movement than just medical students. 

And so in the end when I think about some of the impacts, certainly there's still a long way to go. And I know that many of my colleagues continue to suffer these types of instances. But I do know as well that we did push the needle somewhat. I did notice that after this incident happened and the different advocacy and talks that we gave and the organizations that became involved is we saw some real tangible action. We saw the CMA incorporate things into their code of ethics around intimidation and harassment. 

I saw during my chief residency orientation when I eventually became chief resident that we had sessions around how to support our learners when there is a culture of bullying and intimidation. And I even noticed in my own sites that when we've experienced situations like this within our university, the response from other faculty was very, very different from what I witnessed when I was going through as well. And to me, that makes me really happy because it makes me realize that in some ways this movement did create an impact. 

And then to switch gears a little bit around influencing up, another situation I was put in my first year of practice was I became the de facto leader of the Assessment Center. So it's one of those situations where, again saying yes to opportunities with an asterisk that you never want to burn yourself out. But, of course, pick and allocate your time wisely as Dr. Watterson said. But certainly be open to experiences and new challenges in your leadership. 

And so this certainly was one because I was brand new in practice in my first year but my leadership skills, partially because of some of this advocacy I had done around harassment, and intimidation, and bullying, people had seen me at different stages advocating around this issue is that I was invited to help lead the assessment centers. Now this was something that was unfunded at the time. 

We were really trying to innovate and try and create something that worked in our system because for context where I work as Mississauga Ontario. And that's in Peel Region, which was one of the hardest hit regions in this entire pandemic. We have a lot of essential workers that work in Peel Region. Some of the largest plants for Amazon and many of these places that deliver things all over the country are located in Peel Region. And so we were heavily, heavily hit by COVID. 

And so what became very clear early on was that we needed to innovate and we needed to innovate fast. And we needed to create some sort of system that would be able to balance the fact that we had limited human resources, we had a situation where we had limited access to PPE at that particular time in the pandemic. We had a lot of uncertainty and a lot of fear about what was going on among the community. But also even amongst our colleagues and physicians, nurses across our organization, there was a lot of fear and uncertainty because this was a brand new virus and none of us really knew what we were dealing with. And we were all learning together at the same time. 

And on top of it, we were also in an environment where the health care system at its baseline was already under a lot of strain. And we're seeing it now where you add the extra pressure of COVID and other factors and the system was already starting to buckle. And so I came into this role and asked to help lead this team of physicians, many of whom were senior to me because, again, I was in my first year of practice. 

They were interdisciplinary as well too because of the fact that the COVID Assessment Center work had physicians from every department volunteering and stepping up to contribute their time. And so we had everyone from radiology to anesthesia to surgery to medicine to family practice. Everyone was jumping in to help out. And we were all this brand new team, and I was the leader of this particular team. 

And so for me, it was definitely a situation that was ripe for imposter syndrome. But again I tried to use the principles I had learned when I was in that medical student situation to recognize who my allies were, who are my potential resistors, and how to actually lead change within an organization and galvanize support. 

I developed a vision around what our assessment center could be and what could our potential be as well? Not just could we be trying to do things the way that we used to and that we'd always do in terms of having a stand up assessment center, but what about also trying to do things differently like using virtual care? What about developing a virtual assessment center where we could actually assess patients from their homes and then just bring them in for the swab if they met criteria. And if they didn't meet criteria, save them the trip of coming to the hospital and potentially being infected. 

What if we decided to develop an outreach program where we work with public health and we work with primary care to try and support those efforts? And again using my own background as a new in-practice doctor, I actually use that to my advantage because I knew so many aspects about how the system worked because as residents, we rotate through so many different parts of the system and in some ways that actually gives you a beautiful bird's eye view of how everything works. And you're able to see connections that perhaps people who are in-practice for years and years and years in the same part of the system, they may not see it that way. And I found that was really, really powerful when I was in my role because I was able to build connections that we otherwise may not have thought of. 

And then the fact that I was in my first year of practice, I also use to my advantage because when we faced uncertainty, I acknowledged that as well and people understood that someone in their first year is going to be uncertain as well. And I certainly leaned into that. But then I also brought people along. And I said, how do we solve this problem together and how do we lead change together? 

And so I think a really important part of influencing up and getting people to believe in you as a leader is making sure that you are an inclusive leader that's willing to hear from them and to recognize their experience too and their unique perspective that they bring. And I think that's a key difference from the hierarchical power structures. And I would argue is much more powerful. 

And so in terms of how things turned out, we actually were really successful with our Assessment Center to the point that we were actually even recognized within the hospital as well. And so we developed a virtual assessment center that saw tens of thousands of patients avoided so many potential in-person visits to the hospital and was able to support the hospital at a time that was so crucial during the pandemic. And we were really grateful that amongst over 50 submissions, we were selected as the top Sustainable Innovation Award for that particular year. And that was an award that was presented to our entire team, which we're super proud of. 

So in terms of my key takeaways, the first thing is, start with the vision. Know your why and communicate it because ultimately that's what's going to attract people towards what you're trying to accomplish. You don't need a position. I know my colleagues have said that as well, and I certainly believe that too. There were multiple instances in the examples that I said where I didn't have a lot of power and I had to kind of build that as well. And that's where you're able to actually become a powerful advocate is by generating influence. It's not by having a position. 

A position only goes so far and really you do need to try and leverage those connections and build that influence because that's ultimately what will lead sustainable change and get people to believe in you. And even if you have a position, you still need influence in order to be effective in your position too. So it's not one or the other. You really still need influence. It's ultimately the secret sauce. 

You need to plan ahead as well. So find your allies and know your resistors as well. And even with your resistors, have an open mind. And I love that line that Yan, I used earlier around the fact that you want to see the good and what people are bringing. And even if they seem as though they're resisting your ideas, there's often a perspective behind that too. And certainly I had some challenges when I was leading this group. But I actually learned a lot when I actually sat down and had a conversation and found out what people's challenges were. And it actually made the program much better. 

Certainly, networking is crucial and mentorship is also crucial. I would not have been able to accomplish what I wanted to accomplish without the mentors and the people around me. And I'm ever grateful to them to this day because they certainly helped me had a very, very dark time in my career. 

Your junior perspective is an advantage. So please don't have that imposter syndrome or feeling like you don't belong there because as Yan said, that ultimately shoots you in the foot. If you believe you don't belong there, people are going to believe that too. So you really need to recognize that your perspective is an advantage there. And remember that bird's eye view that you have because you're working across the entire system simultaneously, which very few people do. 

And again, if you have that imposter syndrome, lean into it because sometimes it can be a helpful sober second thought as well and it certainly saved me a few times. When I thought about am I missing something here, should I maybe check this with some of my mentors, and that is very helpful. And people will relate to that. People will understand you if you acknowledge your uncertainty and lean into that imposter syndrome as an advantage, people actually will respect you for it as well. 

And I found that during the case of COVID that when I acknowledge situations where I was uncertain, people did respect me for it in the end as well and we were able to navigate that uncertainty together. And that made me a much more influential leader and ultimately was one of the things that actually drove them to want to recruit me as division head of Family Medicine after I finished that role. 

Staying humble is crucial. So again making sure that we maintain that humility in all that we do, and that will make you a more influential leader. Building bridges is important, but I'd also argue that maintaining relationships is important too because influence, as we've all alluded to, is based on relationships that you have. And so one of the things that I always try and do as well is really try and connect with people that I previously connected with, and even it's informal stuff as well too. 

Because as you become more influential, yes, being liked as is not ultimately one of the most powerful techniques but it does help as well too. And if you spend the time to overtime nurture and cultivate those relationships that you have with others, it will build your influence as well. It's not the only way and I totally agree with what Yan said, that it's not the first method that you need to do. But once you've started to establish yourself, building a nurturing those relationships and connections can actually go very, very far. 

And then again I would just echo what Dr. Watterson said as well, maintain that consistent growth mindset. Failures. I like to think of as a first attempt in learning, F-A-I-L. And I think that that's truly a mindset that we can all take when we think about influence and innovation. 

And lastly, I know that we always talk about saying no to things. But I think in an influence mindset, it is important to say yes, but I do put that asterisk there that our time is limited and you will need to be selective of it. But that being said, if this is something that you're passionate about, that you're willing to put the time into, that financially you're able to support because financial wellness is very important. 

Be open to new experiences and to learning from others and also really keeping that broad mindset of yes, this person may not seem directly involved with what's happening, but they still may be someone who I can learn from and if not, maybe they can build a great connection and relationship that will come in handy down the road. 

And so I'll leave that there. Thank you so much. And again, I'm so inspired by all the work that residents do. I work with them so regularly as an academic physician in a medical teaching unit. So thank you for all you do. And thank you for attending the session.