1. 1 SURGEON PERFORMANCE OPTIMIZATION

2. 2 All of us are performers every day, all the time. We face obstacles, distractions and pressures; we are asked to solve complex problems with inadequate information. Time is often short and expectations are for flawless performance.

3. 3 more lives are saved more diseases cured more functions restored more suffering alleviated than in any other place in the hospital. IN THE OPERATING ROOM

4. 4 HOW ARE WE REALLY DOING? AT WHAT PRICE? CAN WE DO BETTER, FOR OURSELVES AND FOR OUR TRAINEES?

5. 5 The Aching Surgeon: A Survey of Physical Discomfort and Symptoms Following Open, Laparoscopic, and Robotic Surgery Plerhoples TA, Curet MJ, Hernandez-Boussard T, Wren SM. 1407 surgeons (7% response) Ergonomics matter. Patients benefit from laparoscopic technology; surgeons suffer

6. 6 Food for Thought: An Exploratory Study of How Physicians Experience Poor Workplace Nutrition Lemaire JB, Wallace JE, Dinsmore K, Roberts D. Nutrition Journal 2011, 10:18. Emotional, physical and cognitive symptoms reported. We practice hydration and nutrition for our patients, what about us?

7. 7 Hydration and Cognition: A Critical Review and Recommendations for Future Research Lieberman, HR. Journal of the American College of Nutrition. Dehydration impairs cognitive performance Adverse affects are present at 2% Might be present at 1% Krummel experiment

8. 8 Krummel Experiment – My Typical OR Day  Coffee for breakfast  No Lunch  Finished OR day @ 7 PM U/O 0.2 cc/kg/hr AM weight: 80 kg PM weight: 78.5 kg TBW1.5 liter loss 48 liters > 3% dehydrated > 1.5 kg

9. 9 Work-Related Musculoskeletal Symptoms in Surgeons Szeto GPY, Ho P, Ting ACW, Poon JTC, Cheng SWK, Tsang RCC. J Occup Rehabil (2009), 19:175-184. High prevalence of work-related musculoskeletal symptoms. 500 surgeons surveyed Neck 82.9% Low Back68% Shoulder58% Upper Back52%

10. 10 Burnout and Career Satisfaction Among American Surgeons Shanafelt TD, Balch CM, Bechamps GJ, Russell T, Dyrbye L, Satele D, Collicott P, Novotny PJ, Sloan J, Freischlag, JA. Annals of Surgery, Vol 250(3), September 2009. 24,922 surgeons surveyed 7905 respondents (32%) 40% ‘burned out’ 30% symptoms of depression 28% mental QOL >0.5 SD below norm

11. 11 SPECIAL REPORT: SUICIDAL IDEATION AMONG AMERICAN SURGEONS Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, Rummans T, Swartz K, Noyotny PJ, Sloan J, Oreshovich MR. Archives of Surgery 146:54-61. 7905 participating surgeons (31.7%) 501 (6.3% reported suicidal ideation within 12 months) We have >160 surgeons in this department Statistically 10 at risk

12. 12 Physician Wellness: A Missing Quality Indicator Wallace JE, Lemaire JB, Ghali WA. Lancet 2009 Nov 14:374(9702); 1714-21. Abstract When physicians are unwell, the performance of health-care systems can be suboptimum. Physician wellness might not only benefit the individual physician, it could also be vital to the delivery of high-quality health care. We review the work stresses faced by physicians, the barriers to attending to wellness, and the consequences of unwell physicians to the individual and to health-care systems. We show that health systems should routinely measure physician wellness, …

13. 13 THE MAKING OF A CORPORATE ATHLETE “If executives [surgeons] are to perform at high levels over the long haul, they should train in the same systematic, multi-level way that world class athletes train.” Must go beyond wellness  optimization Physical, emotional, mental, values & purpose Loehr J and Schwartz T: The Making of a Corporate Athlete, Harvard Business Review, 2001.

14. 14 RESILIENCE The world breaks everyone. And afterward some are strong in the broken places.

15. 15 FOR CONSIDERATION  The best interests of our patients are served by optimizing surgeon performance.  Biggest leverage point is to start with our trainees. Dr. Ralph Greco Drs. Magee, Salles, Teshome, Zak

16. Dedicated to the memory of Greg Feldman, M.D. Chief Resident 2009-2010 A PROGRAM TO CREATE BALANCE IN THE LIVES OF OUR RESIDENTS © 2011 The Board of Trustees of the Leland Stanford Junior University– Dr. Ralph S. Greco (grecors@stanford.edu)

17. Committee on Balance in Life RALPH S. GRECO, M.D. JOHNSON AND JOHNSON DISTINGUISHED PROFESSOR AND COMMITTEE CHAIR RACHAEL CALLCUT, M.D. CHAPLAIN BRUCE FELDSTEIN, M.D. MARC MELCHER, M.D. CLAUDIA MUELLER, M.D. SURGERY RESIDENTS: GREG MAGEE, M.D. ARGHAVAN SALLES, M.D. MEDIGET TESHOME, M.D. YULIA ZAK, M.D. ANITA HAGAN, RESIDENCY COORDINATOR THOMAS M. KRUMMEL, M.D. EMILE HOLMAN PROFESSOR AND CHAIR PROGRAM DIRECTOR, GENERAL SURGERY RESIDENCY PROGRAM

18. The memory of Greg Feldman is extremely emotional for all of us. He seemed to me to be extremely good at balancing his work and non- work life, and cared about getting other residents to have fun both at and outside work. So it seems appropriate both in content and timing that it be dedicated in honor of him. In so doing, I feel that it is important to not lose focus, because the best way to honor him is to ensure the program has a meaningful and lasting impact on the residents. In my opinion it is important to remember that many of the most impactful aspects of the program are not flashy, but rather the low hanging fruit like advising our residents as we advise our patients - making sure they see their doctor/dentist, telling them to try to exercise and eat healthy, helping them develop healthy coping mechanisms, promoting friendship/socializing among residents, and putting mechanisms in place that can facilitate those basics. Greg Magee, M.D.

19. Greg Feldman’s Harvard Graduation Speech (YouTube video) hmsedited_smaller.wmv

20. too many beeper calls and scut too little time to study too little sleep too little time with family too many bad outcomes too little money too much pressure too much criticism too little respect too little support too much ridicule just too much!! “THE TERRIBLE TOOS”

21. Physical Health It is the expectation of the Stanford General Surgery Training Program that all surgical residents will take their physical health seriously and Schedule regular appointments with primary care physicians and dentists Eat a healthy diet Exercise

22. Primary Care Physicians Dentists OB/Gyns Gyms Hiking/Biking Trails Restaurants Local Travel “AFTER HOURS” BROCHURE

23. Resident Refrigerator in the Goodman Simulation Center

24. Psychological Health Balance in Life Class Meetings Lisa Post, Ph.D. Finding Meaning in Medicine Chaplain Bruce Feldstein, M.D.

25. Team Building Retreats, Ropes Course, Big Sib/Little Sib Social Program Elect---------formulate

26. Structural Issues Space Resources Forums Elect class representatives Monthly meetings ACGME Presentation-March 2012

27. Program Management Resident Leadership “The Fab Four” Greg Magee (2011-2012) Mediget Teshome (2012-2013) Yulia Zak (2013-2014) Arghavan Salles (2014-2015)

28. What Happens Now How do we guarantee that the program doesn’t dissipate over time? Resident leadership at multiple levels Endowment

29. just the right amount of work just the right amount of time off just the right amount of sleep just the right amount of time for family and friends just the right amount of patient contact just the right amount of support just the right amount of teaching just the right amount of OR cases just the right amount of respect “THE JUST RIGHTS”

30. Resident Wellness is Performance Optimization Greg Magee Arghavan Salles Mediget Teshome Yulia Zak

31. Poor Occupational Health is Costly –The total cost of stress to U.S. organizations is more than $150 billion a year. 1 –Occupational stress leads to multiple problems: 1, 2 Substance abuse Accident proneness Sleep dysfunction Sexual dysfunction Depression

32. Improving Employee Well-Being Benefits the Organization 1 Improving employee well-being can: –Reduce absenteeism –Reduce turnover –Improve mental alertness –Improve job satisfaction –Improve productivity Which in turn leads to better patient care

33. Well-Being Improves Productivity 3 Employee Engagement Positive AffectProductivity Gallup’s meta-analysis of data from 21 industries and nearly 200,000 individuals found that companies with greater employee engagement had -lower turnover rates -higher productivity -greater profitability

34. Overview of Proposed Programs Physical Well-Being Leadership Development Psychological Well-Being Social Well-Being

35. Physical Well-Being Leadership Development Psychological Well-Being Social Well-Being

36. Health Maintenance International issue Only 42% of Australian physicians had a general practitioner. 4 30% of young Irish physicians had not been to a general practitioner in the previous 5 years. 4 65% felt unable to take time off from work when they were ill. 5

37. Doctors work despite being ill 6 61% despite vomiting all night 83% despite blood in their urine 76% despite a suspected stomach ulcer 73% despite severe anxiety

38. Emergency Coverage Description –It is difficult for residents to take time off to see their physician or dentist. –We will now require residents to do so. Goal –Ensure that residents take care of themselves

39. Healthy Eating Description –Refrigerator in Goodman Surgical Simulation Center –Barriers to healthy eating among physicians are related to food selection & availability. 7 Goal: To provide access to healthy food options

40. Exercise Goal: To prioritize exercise and healthy living Description –Encourage residents to exercise regularly –Provide list of local gyms, outdoor activities –Exercise is associated with high well-being in various facets of employees' lives. 8

41. Physical Well-Being Leadership Development Psychological Well-Being Social Well-Being

42. Analyze This Employee counseling benefits: 9 –Decrease anxiety and depression –Improve productivity –Decrease absences –Lead to greater job satisfaction Description –Residents meet with psychologist Lisa Post Goal –Give residents an opportunity to discuss problems in a safe environment with a professional

43. Lisa Post, PhD Director of Health Connect Chief, Sports Medicine in Psychiatry Extensive experience in inter- personal dynamics counseling and psychosocial treatment Consulting psychologist for the San Francisco 49ers Instructor, Rookie Conduct Management/Rookie Success Program for the National Football League

44. Physical Well-Being Leadership Development Psychological Well-Being Social Well-Being

45. Class Representation Description –Each class elects a representative to meet with the Well-being Chief monthly –Brainstorm solutions to problems Goal –Provide a forum to discuss active issues –Generate solutions –“The best way to have a good idea is to have lots of ideas.” -Linus Pauling, winner of two Nobel prizes

46. We’re Looking for a Few Good Residents

47. The Value of Mentorship 96% of orthopedic residents considered mentors critical to their training. 10 Mentorship plays a significant role in career development for physician leaders. 11

48. Peer Mentorship Description –Junior residents will select senior residents to serve as mentors. Goal –Help junior residents navigate the residency experience

49. Team Building Description –Work together towards a common goal –Ropes course –Workshops Team building programs improve outcomes. 12 Goal: To build trust and collaboration amongst residents

50. Physical Well-Being Leadership Development Psychological Well-Being Social Well-Being

51. Social support Description –Organized events such as sports outings, hiking, biking & exercise, dinner/happy hours Social collegial support is positively correlated with improved physician satisfaction & organizational commitment. 13 Goal: To foster a sense of community

52. Measuring Impact Self-report measures such as: –Burnout –Depression –Belonging Behavioral measures such as: –Absences –Patient care metrics

53. Conclusions Resident well-being is crucial for optimal hospital operation. We appreciate your support in making our hospital a safer environment for both residents and patients.

54. “ Work should ennoble, not kill, the human spirit. Promoting workers’ well-being isn’t just ethical; it makes economic sense.”