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Flourishing in Medicine: From Surviving to Thriving Episode 4 Tim Cunningham, RN, DrPH, MSN, FAAN · Flourishing in Medicine: From Surviving to Thriving

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Welcome back to flourishing in medicine from surviving to thriving.
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I'm Dr. Mick Krasner hosting this podcast which is produced by EmPRO, a medical professional
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liability assurance carrier headquartered in New York State.
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EmPRO is dedicated to protecting New York, New Jersey, Connecticut, and Pennsylvania's
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physicians, health care facilities, and health care providers, and it offers a host of peer
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support activities including this.
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Flourishing in medicine explores ways health professionals can flourish in the complex
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and challenging world of health care.
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And today's guest is a colleague, a friend, and really an inspiration.
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I hope you will find as I do his enthusiasm and experiences and point of view and inspiration
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for you.
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Dr. Tim Cunningham is vice president of practice and innovation at Emory Health Care in Atlanta,
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where he also functions as co-chief wellness officer for the Woodruff Health Sciences Center
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Office of Well-being, EMWELL.
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He is an adjunct associate professor in the Neil Hodgson Woodruff School of Nursing.
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And before joining Emory, Cunningham served as the director of the University of Virginia's
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Compassionate Care Initiative.
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Clinically, his background is as an emergency and trauma nurse, and he's worked at multiple
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level one trauma centers in the United States, while also having served clinically in humanitarian
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crises such as the West African Ebola outbreak post 2010 earthquake in Haiti, and in the
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ongoing humanitarian crisis in Myanmar-Burma-Bangladesh border.
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His research and publications focus on methods to advocate for well-being while measuring
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the impacts of specific wellness related practices.
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Tim co-authored a book called Self Care for New and Student Nurses in 2020, which examines
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ways to keep well-being relevant for the individual as well as for the health systems.
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I was fortunate to be able to contribute a chapter to the book, which honored Dr. Dori
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Fontaine, the now retired dean of the School of Nursing at the University of Virginia.
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A registered nurse by clinical training with a specialty in emergency nursing, Tim holds
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a doctorate in public health from Columbia University, but perhaps his most important
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credential that gives him the authority to speak on flourishing is his work as a professional
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clown, and involvement in Clowns Without Borders, where he has given humanitarian healing aid
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through clowning to some of the poorest and most conflict-ridden settings on our planet.
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In our conversation with Dr. Cunningham, we explore how the process of burnout touched
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his family and created a spark within him to become a health professional, and how important
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he is found to stay connected with a sense of meaning to inoculate him against burnout.
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He discusses the challenges in his current role and challenges for chief wellness officers
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in general with a practical approach of using empirical evidence to drive leadership, innovation,
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and change.
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He predicts that soon the return on investment in medical staff well-being will become a
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no-brainer with such strong evidence that he expects he'll be out of a job at that
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point.
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And that would be just fine with Tim.
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You may find the parallels and connections he makes between clowning, theater, and health
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care not only entertaining, but also poignant and accurate as he shares personal stories
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of all of that.
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His take on flourishing in medicine, quite simply, is about making space.
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As he says, healing can really resonate when we create space.
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Maybe it's not us flourishing.
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Maybe this podcast should be about how we just let health flourish or healing flourish.
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Tim is truly a gift and inspiration and a force in wellness that is full of presence
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and compassion.
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I hope you enjoy this conversation with Dr. Tim Cunningham.
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Tim, welcome to Flourishing in Medicine, From Surviving to Thriving.
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We're really happy to have you as a guest.
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And I'd like to start with something that I start all my discussions with guests with
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is, you know, I've been impressed through my experiences in medicine, especially as
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educator, students, colleagues, staff, academics, whatever roles they have, but they're in health
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care that sort of the common role.
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I've been impressed with their narratives when we start to ask them, tell us a little
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bit about, you know, what were some of the formative experiences that you had that really
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convinced you, inspired you, thrust you into this life as a health professional, life as
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a nurse or some other clinical life.
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And what's been so amazing is, you know, there's poignant stories, there's very profound stories,
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there's often encounters with illness, aging, death, close, personal, sometimes in communities.
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So there's all these really rich combination of things that draw us all together in some
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ways kind of our, one could say, archetypal story.
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So we want to hear like, what is the origin story for you?
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How did you get here?
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And what were some of those early experiences you'd be willing to share with us that have
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led you here?
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Mick, thank you for that question.
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And I want to begin by just thanking you for this opportunity to share some ideas on this
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podcast.
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It's great to reconnect with you and to have known you for many years as you've kind of
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seen me change throughout my professional journey as well.
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There are two origin stories that come to mind.
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And I want to share both.
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I hope you can have plural origin stories.
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I don't know if that's a thing or not.
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But the first one is one that I literally learned a couple of years ago.
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And this is in reflection of my current work as co-chief well-being officer for the Woodruff
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Health Sciences Center and Emory Health Care in a leadership role, working with professionals,
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health professionals on how we can improve the workplace so people can be their best
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selves.
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And I realized one of my initial callings to this role, which I did not know when I
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was 17 years old when it happened, was that I nearly lost my father to burnout.
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And what I mean by that is that my father is a retired dentist.
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He is still with us gratefully.
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And he was so burnt out.
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He was so frustrated with the systems he was working in.
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He didn't want to run a business.
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He wanted to treat people.
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And I grew up in a small town and everybody knows him.
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And he treated so many people, so many of my friends.
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But he fell deeply into many of the negative symptoms that we see related to burnout and
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literally almost lost his life.
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I learned a couple years just a few years ago that there is a deep family history of
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suicidality within my family.
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And so all of these pieces are coming together.
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And I think I realized at a very early age that I was called to do something to help
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reduce the burnout of our healers.
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And when I say healers, I mean physicians, I mean nurses, I mean APPs, NPs.
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I mean the front desk staff person that our patients meet when they walk into a place
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that should be a place for healing.
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So I reflect on gratefully not losing my father, but the trauma that that caused our family
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and seeing how negatively burnout can impact our nation's healers.
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So that's one.
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Two, I became an emergency nurse because I had the opportunity.
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I was an actor before I became a nurse and I volunteered with an organization called
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Clowns Without Borders.
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The mission of Clowns Without Borders is to share levity and joy and playfulness in zones
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of suffering and crisis.
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And so I was invited in 2006 to work with a team of clowns in rural Haiti in a pediatric
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hospital and we did our clown thing.
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We had docs and nurses engaging with us, dancing, playing, kids sitting up in their beds laughing.
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I saw all these medical conditions that I was to learn about later and then all the
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textbooks and I saw firsthand tetanus, in-stage AIDS, I saw tuberculosis, all sorts of things.
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But the thing that changed my life was that at the end of our time working in the hospital,
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we were shuffling our way out as clowns and there was a group of people around a bed.
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And that was one of the first beds that we performed at when we came in about an hour
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prior.
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There was a child who appeared to be sleeping and the mother of this child asked if we would
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play a quiet song for the child over the child.
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So we did.
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The mother smiled, she hugged us afterwards.
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The father was there and he shook our hands and gripped them really hard and they said,
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thank you.
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And then we went around to see other kids.
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Well, that child was actively dying.
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And at the time when our show ended and we walked out of the hospital, the child had
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just passed away and she died from malnutrition, Mick.
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She died because mom didn't have adequate nutrition while she was pregnant and the child
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struggled with malnutrition.
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And I remember literally physically feeling a shock through my entire body and deciding
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that day that I wanted to understand more.
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Why does a child a few hundred miles from the coast of a country where we spend more
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money on healthcare than any planet in the universe, as far as we know, why does this
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kid who's so close to our country die because she just can't get enough [food]?
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So I was interested in health equity and inequity and interested in how I could become more
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active as a healer to understand that.
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So became a nurse and now I find myself in an executive leadership role.
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So you talk about the clowning, doing that clown work that you did in Haiti in a setting
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of lots of different kinds of suffering and still the capacity we all have for joy.
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I just want to connect it a little bit with maybe we have to define it a little bit differently,
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the kind of joy that we as health professionals can sometimes derive from our work.
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Maybe you can talk a little bit about joy and meaning as a health professional and whether
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it's important.
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If you believe that it is important, what do we mean by joy and kind of what are the
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ways in which we can get there?
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We can have joy even doing that kind of work and it sounds like for you that experience
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was very profoundly touching and changed your life.
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But I would dare say, and correct me if I'm wrong, is there's a little element of joy
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there being in that situation.
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That's absolutely right.
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And the joy, when we say joy, I think we sometimes connote this idea of happiness and everything
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is great and perfect and right.
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And yet I have felt joy in some of the most profoundly painful situations.
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And I think from a professional standpoint, Mick, that's such a great question about what
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does that joy look like?
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We often say or people say laughter is the best medicine.
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And I just think that's a lie.
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It's just not true because there's some extraordinary medicine out there that can do a lot more
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than laughter.
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And at the same time, Mick, so long as we're breathing, we have the ability to laugh.
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And when we think about joy in the health professions and so long as we are engaged,
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as we are acting, as we are witnessing someone's suffering, feeling their pain, which is empathy,
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doing something to reduce that suffering, which is compassion, from that we experience
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a sense of joy.
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And from that joy, I think that is the joy.
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I think of the poem Kindness by Naomi and Ihab Shah.
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And she says, you know, it's only until you know suffering, it's kindness that gets you
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out of bed in the morning and ties your shoes and takes you out into the day to gaze at
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bread and then follows you like a shadow or a friend.
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It's that same joy that gets us out of bed in the morning or in the evenings to work
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overnight or in the morning to work during the day.
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Feeling that we are doing something that is compassionate, which is healing.
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And I mean, there's proof of it.
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When I was doing my doctoral dissertation, I have a doctorate in public health.
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And when I was doing my dissertation work, that was around about the time of the West
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Africa Ebola outbreak.
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And I had the opportunity to do my dissertation on looking at burnout of frontline caregivers
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treating people with Ebola.
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I worked as a nurse on the front lines for about nine weeks in Sierra Leone doing the
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work.
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And then when I came home, I interviewed people to ask about burnout, assuming that our teams
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would feel tons of burnout.
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But Mick, what we learned in this work, me and my colleagues, was that very few people
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felt any burnout.
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Physicians, nurses, caregivers, even though we were exposed to Ebola every day, we didn't
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have enough supplies.
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We literally had nine medications in our entire pharmacy.
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We saw so much suffering and death to the tune of sometimes tripping over corpses when
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we would begin a shift because there was so much death.
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And at the same time, there was a profound sense of joy, not that people were suffering,
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but joy that we had meaning in everything we did every single day.
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And Mick, I think joy, I'm going to get a little snarky here, joy in that we didn't
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have to chart every dag on thing in the electronic medical record.
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I treated this patient with this.
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I gave this patient this.
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This patient appeared this way.
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We didn't have any computers and we didn't have time to do it.
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So I think joy in the health professions for physicians and nurses comes from knowing that
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we have meaning in our work.
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And I'll just end with, it scares me to death to meet with physicians who are choosing to
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leave the workforce right now because they've lost that connection with their own meaning
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in work.
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They say things like, I signed up to be a healer and I am being incentivized to generate
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revenue.
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I am being incentivized to be really good at charting.
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I'm being incentivized to be fast.
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But I think the true meaning and healing, we should be incentivized to heal and that
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should take as long as it needs.
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Yeah.
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I couldn't agree more with you.
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And it's a real challenge for us.
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It's a shame that it has that effect on people, that they lose that connection.
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For you, the connection and a word that's come up already a number of times in your
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sharing is compassion, taking action to alleviate the suffering, would be one definition, suffering
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of others.
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And then the origin story, the first one you told, one could have had an experience of
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a close family member, a father in your case, who was traumatized in some ways and almost
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lost his life as you described from the ravages of burnout.
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And you could have chosen to do something else and say, I don't want to get anywhere
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near this.
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But there's something about this drive we have because we're a social species to connect
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and also to take care of each other.
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It's actually one of the reasons why we have been up till now fairly successful, very successful
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as a species, compassion.
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So yeah, maybe you could talk a little bit about the ways in which compassion shows up,
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even now in your work as a co-chief wellness officer and your work in a large health system,
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but also as you work as a nurse in the bulletins or even in the clinic, in the pediatric clinic
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or in the emergency ward where you've worked quite a bit.
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So much of what you're talking at and talking towards and into the space of compassion,
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Mick, I think begins with showing up.
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And I want to give credit to you.
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I began learning about how to show up in healthcare from some of your early papers.
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I had the opportunity to start to learn mindfulness when I was at the University of Virginia by
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a very, very generous donor and colleagues and people who exposed me to that work.
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And much of the early papers were papers that you and colleagues had written in practicing
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mindfulness.
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And to really put that in a nutshell for me, it begins with showing up and practicing showing
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up and practicing showing up again and again and again and again.
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I also think of the words of Mr. Rogers, Fred Rogers from Mr. Rogers' neighborhood who said,
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you know, when there's a crisis, when there's a concern, look for the helpers.
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Who are the people that are showing up?
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And in this ever complex world that we live in, it is the physicians that have showed
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up since the beginning of time.
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It is the nurses who have showed up since the beginning of time.
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Look at any war, look at any natural disaster or greed-inspired disaster or any sort of
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disaster.
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And who's always showing up?
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It's physicians, it's nurses, it's caregivers, and it's healers, whether they have the letters
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behind their name or not.
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So when we think about, for me, compassion begins with showing up and a desire to show
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up.
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My father told me not to go into anything related to healthcare.
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He was so broken and burnt out.
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And so I went into acting.
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I took his advice.
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I majored in English.
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I went into acting.
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And so I had to relearn the sciences to get back into nursing school about seven years
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out.
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But I think it is as we are all human, as we are all working to survive together as
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a species, we are learning more clearly that it's compassion that will keep enabling us
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to show up.
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And when we can't do it, when we are feeling exhausted, when we're having what a lot of
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people are calling empathy fatigue, we used to call it compassion fatigue.
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I think that's a misnomer because you can never exhaust yourself or be exhausted from
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compassion.
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John Halifax talks about this.
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There are other writers and scientists that say, no, compassion is, that can be a wellspring,
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but empathy, you're going to run out on that.
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And when I witness you, Mick, do something compassionate, I could have some empathy fatigue,
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but if I see you do something compassionate, my mirror neurons are going to fire and I'm
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going to be inspired to do something else compassionate and I'm going to feel good about
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myself.
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So it begins with showing up and then it begins with noticing, paying attention mindfully,
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how you show up, noticing how other people show up and then feeding off of that.
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And it's like this beautiful positive feedback loop of the more we show up, the more we show
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up and the more we show up, there's more compassion and the more compassion, the more showing
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up.
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It's not very scientific, I don't think, but I hope that kind of makes sense.
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I think it makes complete sense.
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And in some ways, this compassion, you're talking about how does one flourish and use
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that positive reinforcing.
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In fact, we are physiologically designed to be compassionate because we gain some very
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powerful biochemical messages that reinforce that, that say this is good, it should feel
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good and keep doing it because it's good not only for you, it's good for your species,
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it's good for your loved ones, it's good for your patients, we can go on and on.
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I just want to shift slightly your current position at Emory Health includes, you know,
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Co-Chief Well-being Officer and many listeners, including myself, even now with all the years,
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number of years that we've had wellness officers in our institutions and large healthcare organizations
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wonder, what is it?
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You know, I think it's in some ways a placement in an organization that still is defining
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itself, who are the groups whose well-being your office is charged with and what impact
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can a position like this have on well-being, especially for health professionals in an
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organization like this?
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So maybe talk a little bit about your position, how it came about and how do you approach
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it philosophically, physically, emotionally, cognitively, all the ways in which we approach
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things?
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A question I frequently get is, hey, Tim, as Co-Chief Well-being Officer, what do you
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do?
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And you named it and there have been many offices of well-being out there for a while
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and it's, we're continuing to learn as we do this work in many ways.
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When we talk about our work in our office, and I am a Co-Chief, I share this role with
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a colleague of mine, Dr. Chad Rittenhour.
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We're one of only a few offices nationally that are co-led by a nurse-physician partnership.
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And I think that also brings a lot of benefit to the work we do.
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And I'll begin with scope.
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The scope of our office is in service of our entire teams.
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I like to say from our valets to our vascular surgeons.
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We also cover our health sciences schools, so our School of Medicine, Nursing, Public
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Health, and we have a National Primate Research Center that we're learning a lot of interesting
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things about.
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I'll come back to that.
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But we cover our researchers, we cover our students and faculty and staff as well, from
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our A to Z, our anesthesiologists, all the way to our zoologists.
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Because we firmly believe philosophically that when it comes to well-being, John F.
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Kennedy was once credited of having said, a rising tide lifts all boats.
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And so we believe from our office that when our team is well, patients will flourish.
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But for patients to flourish, our teams have to flourish.
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And when you focus on team well-being, as opposed to just nurse well-being or just physician
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well-being, that enables a physician to walk into work and having a really bad day.
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Because if your team is healthy and well, your team is going to lift you up.
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If you're having a great day as a physician leader and your team is not doing well, then
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you've got that extra energy to lift them up and support them.
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So that's the woo-woo level of how we think about well-being, how we enacting it.
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And that's where it gets really difficult.
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There are over a decade of great research on physician burnout.
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One thing we're really good about in the well-being space is measuring how badly we're doing.
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We're so good at measuring burnout.
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We're so good at measuring suffering.
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And a research colleague of mine from the University of Virginia would always remind
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me, he said, Tim, the harder you look to measure something, more likely eventually you're going
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to find it.
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Just keep building that sample size up.
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You're going to get it.
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You're going to find significance.
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We're trying to shift that narrative when it comes to measurement.
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Can we use scales like there's the post-traumatic growth inventory by Tadeshi and Calhoun.
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Can we look at scales like that to measure the strengths, to measure what's working?
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Because we also, I mean, the more surveys you fill out on how burnt out you are, you're
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probably going to get burnt out on the surveys and also start to feel bad about yourself
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when you realize, wow, I'm in a really rough spot.
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So there are aspects of measurement of knowing where we are.
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And then more importantly, our work in our Office of Wellbeing is about systemic and
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structural change.
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And what I mean by that is working with teams to examine, for example, our leave policies.
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If you're a person that works at Emory Healthcare and you want to have a child, are we offering
24:36
you the most evidence-based leave policies that are going to give you as much time as
24:41
possible to be home with your kid, for one?
24:44
From a nursing perspective, we changed a policy early on.
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We used to have a policy that said, if you're caught sleeping on the job, it's immediate
24:50
termination period.
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So we worked and we changed that policy to say, if you are an hourly worker, like a nurse,
24:58
a technician, someone that's not salaried, you get a 30-minute unpaid lunch break.
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So we changed the language to say, if during your 30-minute unpaid lunch break, you can
25:06
safely take a power nap outside of patient care and patient view, we support that because
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your rest is important.
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Because Mick, if the nurses you're working with are well-rested, your team is going to
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function that much better.
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So our office is looking at those structural policy changes.
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We are also advocates for well-being.
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We have chief titles.
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So we sit in the executive suite, the C-suite, and a big part of our job is, let's go back
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to Compassion, Mick, it's showing up and it's advocating for how are these decisions going
25:40
to support the well-being of our team?
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We ask our leaders, how are you looking at this decision through the lens of well-being?
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But frankly, that's a foreign concept to a lot of executive leaders because what we don't
25:52
yet have nationally, which we will have, I give you my word, hopefully sooner than later,
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but we don't yet have, is a revenue generating system to show how well-being support will
26:02
make money for a hospital.
26:04
We don't have that ROI in the traditional ROI sense.
26:08
We're getting close and when we have that, we're going to see a major shift in the way
26:14
we think about well-being because as much as we are healers, we work in a capitalist
26:19
system that is about generating revenue.
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And if that's not going to change, which it probably won't change soon, then we have to
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address our well-being conversations and incentives and initiatives around a revenue generating
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structure.
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So that's the long game.
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Back to the short game in advocacy, it's also being seen and seeing people.
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It's meeting with individual team members and helping them think about how do they care
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for themselves?
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What do they do for personal resiliency while we're trying to shift cultures and support
26:50
workplace well-being?
26:51
I mean, I think it's undeniable that if your caregivers are well, patients are going to
26:57
do better because we know when patients feel seen, heard, and truly cared for, they will
27:04
thrive.
27:05
And we also know that the only way that someone can give the care that the humans that we
27:09
treat deserve, it has to be a thriving person.
27:12
Yeah, I really like a couple of things that you said I want to reflect on.
27:15
One is turning not only at the data that tells us how bad things are, but looking at the
27:22
strengths and capacities.
27:24
This appreciative approach and appreciative approach we use, as you probably know, in
27:30
our mindful practice and medicine training, and it is actually much more highly motivating
27:36
to look at and to carry forward things that are working right now.
27:40
And there are things that are working right now.
27:43
On the other hand, as you mentioned, measuring the cost of healthcare staff burnout is difficult,
27:51
but we're good at measuring stuff.
27:53
And like you say, it can be done.
27:55
There are estimates that are just astounding on what it's actually costing, and believe
28:00
me, that will get the attention of the C-suite, your chief financial officers, your chief
28:04
operating officer, your chief executive officers will all pay very close attention and then
28:10
try out a variety of things that could work.
28:14
I wanted to ask you kind of an odd question, but in this role you have, can you connect
28:19
for us?
28:20
Because, you know, there's a thread through all of our lives that sort of run and you've
28:24
beautifully shared with us the threads that are important to you in terms of compassion
28:29
and in terms of, you know, showing up through nursing, through clowning, through acting,
28:35
through medicine.
28:37
What is the connection between this professional role you have now and clowning?
28:45
The connection between this professional role I have now and clowning is getting more and
28:50
more clear to me every single day.
28:53
Wow.
28:54
I love that question.
28:55
One word, art.
28:57
Clowning, and for the audience, and I want to be mindful that there might be some people
29:02
listening right now who are afraid of clowns.
29:03
I'm going to try to be very clown neutral.
29:05
I don't want to trigger anyone or have anyone jump off the podcast.
29:09
So Mick, I've worked in about 21 other countries with the organization Clowns Without Borders
29:14
and some other theater companies, including the U.S., and it's only in the U.S. that I've
29:17
met people that are legitimately afraid of clowns.
29:20
And that's a whole curious conversation for another time.
29:24
What a clown is, when clown is done well, it's art.
29:29
And the art form is listening, reading the audience, and then giving back to the audience
29:37
something that they need they don't even know they need.
29:40
And the clown is the master of juggling, of acrobatics, of physical comedy, maybe of magic,
29:47
of movement, of maybe verbal improv.
29:50
But the best clowns are the ones that are really good at improvising in the moment,
29:54
taking what the audience gives, responding to it, and then actually giving the audience
29:58
what the clown knows they're going to do anyways.
30:00
But they work it in a way that the audience feels like, how did that clown all of a sudden
30:04
start juggling?
30:05
How did they know that's what I needed?
30:07
The clown as an artist has the ability, and I learned this from Rita Sharon, who's done
30:11
a lot of great narrative medicine work at Columbia University.
30:14
Rita talks about the space in between, between the provider and the patient, and seeing that
30:21
space and addressing that space and addressing that energy.
30:24
The clown does the same thing with the audience.
30:25
Here's what the audience has and needs and sees.
30:28
Here's what the clown has and needs and sees.
30:30
And here's how the energy between the audience and the clown interacts, and the clown responds
30:35
appropriately, leading to laughter, which is healing.
30:40
How does this apply to my current profession?
30:42
My current profession and role, even though I sit in an executive suite and I'm not on
30:46
the front lines anymore, is more about healing than any role I've ever had.
30:50
But it's about healing and supporting so many people at once, much broader voices.
30:57
And I practice clowning every day with it.
30:59
It begins with paying attention, showing up.
31:02
It also begins with, I can't tell you how many ideas, Mick, I've brought forward that
31:05
have the no is, I hear no all the time.
31:10
And so clowns are also resilient, like a clown trips and falls and pounces back up and keeps
31:14
going.
31:15
A clown never gives up.
31:17
And so, and an artist is constantly refining their craft and their skill, doing what they
31:22
can do, and then seeing how it can be better and doing that.
31:26
And that's what we're trying to evolve with the wellbeing work.
31:29
And also communication.
31:30
I mean, if you can't communicate this stuff well, you're going to lose your audience like
31:34
that.
31:35
And so I'm constantly learning now, what is my position in this theater?
31:39
Because Mick, I think it's all theater.
31:41
And maybe all of life is theater and how we engage with one another.
31:46
I would not have this job if I had not had the clown training.
31:49
Absolutely.
31:50
Yeah, you make a compelling case for that.
31:53
Yes, absolutely.
31:54
So, you know, I would think the listeners must be really curious.
31:58
I'm certainly really curious.
32:00
Maybe you can share a story or two, as you described that space that is created in the
32:06
clowning experience, in your work experience.
32:09
Maybe share a story from your clowning, because I think we would love to hear that, where
32:15
something happened that has just stayed with you, has been a source of inspiration, a source
32:19
of joy and meaning that maybe in the telling of it, you will re-experience that and that
32:27
you may draw upon in the future when you have challenging moments as we all have.
32:32
Two stories come to mind.
32:34
And one that applies more to my work when I was working fully in the clinical space.
32:40
And the other applies more towards my leadership work.
32:42
And I hope the audience will hear the second one in a place of mentorship and recognizing
32:47
how beautiful your audience is right now in that they continue to practice healing in
32:54
a place where healing is not necessarily incentivized.
32:57
So let me go back to the first story.
32:58
First story, I was working with Clowns Without Borders.
33:00
We were invited.
33:01
This was in Texas.
33:03
This was right outside of Austin, Texas.
33:05
Our organization was invited to work in a series of safe homes for women who had been
33:10
abused at home, who had children.
33:13
And it was a place, literally, we met our guide at a McDonald's and they said from this
33:19
moment on, you don't write down addresses.
33:21
You don't report where we went.
33:24
And it's safe lockdown.
33:25
And we go in, we do our clown show.
33:28
And part of the clown show, we do this really dumb bit where I pull a handkerchief out of
33:32
my pocket of my tuxedo tails and it's a red handkerchief because I have to sneeze and
33:37
I sneeze.
33:39
And then I try to get it out of my hand, but it's stuck to my hand because it's full of
33:42
boogers and snot and do this whole funny bit where I pull it out of my hand and I trip and
33:47
I fall and I can't get it unstuck.
33:49
And then finally, I go up to a child in the audience who is usually by that point reaching
33:54
out to help me get it unstuck.
33:56
And a child reaches her hand up and then she takes the handkerchief out of my hand.
34:00
And then everybody laughs because the kid is like, you know, figures it out.
34:04
And then I take it again and then I make it magically disappear in my hand, goes away,
34:08
and then it comes out from behind under my hat.
34:10
And then it goes away again in my hand and I pull it out from behind another clown's
34:14
ear.
34:15
And then it disappears a third time.
34:18
And then I'm like, where is it?
34:20
And normally I look in the audience to see if a kid raises their hand to see, oh, me,
34:24
me, me.
34:25
And this particular show, this child who pulled it out of my hand originally when it was stuck,
34:30
raised her hand again.
34:31
And she was laughing and playing and looking at her friends.
34:34
So I went up to her and I pulled it out from behind her ear and she stood up and just laughed
34:39
and screamed, laughed like really, really happy.
34:41
And then she sat down and we finished our show.
34:44
At the end of the show, one of the psychologists that was working there came up to me and said,
34:50
how did you how did you know to pick that child?
34:53
And why did you pick that child?
34:54
And I said, well, I was just picking up connection and energy from her.
34:58
And I thought, you know, she she felt safe enough and comfortable enough to do this.
35:02
So we engaged in the thing and it went well.
35:06
And then I asked, I said, did I do something wrong?
35:08
Is there a concern?
35:09
Because we have to keep checking in as clowns, especially working with vulnerable people.
35:13
And the psychologist said, I'm not concerned, but this is the first time since this child
35:18
arrived a few days ago that she's made eye contact with anyone, that she was willing
35:22
to actually touch anyone.
35:25
Like when and they said, when you came up to her, we were really afraid that she was
35:28
going to have this massive fear, panic response just because of the history that brought her
35:32
to that place in the first place.
35:34
And they said, but she freely reached out and engaged with you.
35:38
How did you do that?
35:40
And that, Mick, I think is healing.
35:42
And that's healing from showing up.
35:43
And that's healing from doing what you know how to do when it needs to happen.
35:50
How do physicians continue to work as healers in places where they can flourish?
35:54
My second story is about the long-term impacts and how we help our patients flourish.
36:00
I was living in New York City at this time and Clowns Without Borders was invited to
36:05
give a presentation at the World Bank down in Washington, DC.
36:08
We had, we got a really big donor out of it.
36:10
We had a couple of smaller donors who said, hey, this could be a good enrichment program.
36:14
Come to the World Bank, give a presentation.
36:16
So I came to the bank, my presentations on Clowns Without Borders, I begin them in clown
36:20
gear, doing my clown thing.
36:22
And then over time I take off the nose and I take off the hat.
36:25
Then I talk about the impacts of our work.
36:27
So hour long presentation at the end of the presentation, and people are laughing and
36:30
having a good time.
36:31
At the end of the presentation, we have, you know, mics set up, like, you know, in all
36:34
the conferences where people come up to the mic and they don't ask questions, but they
36:38
just brag about like, I did this and I have these degrees.
36:41
And then you're like, are you going to ask a question or not?
36:44
So we had the mic set up and this woman walks up to the mic and she says, I don't have a
36:49
question, but I want to say thank you.
36:53
And she said, when I was a child, I lived in Croatia and I spent much of my childhood
36:59
living in a refugee camp.
37:01
And she said, I very clearly remember one Christmas time, Clowns Without Borders came
37:05
to our camp.
37:06
This is like the early nineties, late eighties, early nineties, I guess.
37:11
The clowns came to our camp and they did a show.
37:14
And she said for every year at Christmas time after, even though the clowns only came one
37:18
time, I would get together with my girlfriends and we would reenact the entire show.
37:24
And she said, that's a memory that stuck with us, still sticks with us when we are now here.
37:31
She is working at the World Bank.
37:32
She's a global leader.
37:34
That's something that sticks.
37:37
It's the stuff you can't predict sticking that sticks.
37:40
It's the moment as a physician that you sit next to your patient and hold their hand.
37:45
It's that moment as a physician that you give more time to your team, that you hold that
37:51
space.
37:52
It's that moment as a physician where you take off your hat and Nick, you actually wrote
37:56
this in the textbook that you submitted a chapter to.
38:00
When you practice beginner's mind, that is an act of compassion and you show up and you
38:08
pay attention.
38:10
And I think both of those moments helped me see how healing can really resonate when we
38:16
create a space.
38:17
Maybe it's not us flourishing.
38:19
Maybe this podcast should be about how we just let health flourish or healing flourish.
38:22
I don't know.
38:23
But we have-
38:24
It's a good thought.
38:25
It's a good thought.
38:27
Wow.
38:28
Wonderful story.
38:29
Very touching, very moving for me to hear that.
38:32
I have two more things before we finish up.
38:36
As a nurse and an expert in public health, you've really beautifully articulated words
38:42
about compassion.
38:44
And in one TED talk, you talked about quote, unforgetting compassion.
38:51
So kind of another way of saying remembering, but you said it as unforgetting compassion.
38:57
Maybe you can just share with us what you meant by that idea and a little bit about
39:01
you also talk about this activation of the ventral part of our nervous system that is
39:06
a salve, is a balm toward flourishing and also looking up.
39:12
Maybe if you can bring in those three little concepts together.
39:16
Absolutely.
39:18
When I use the term unforgetting in my TED presentation, I thought about, I created that
39:24
term for that talk in recognition that as healers, we are born healers, we are born
39:31
compassionate, we are born.
39:34
And there's evidence that says if we look at some of the medical evidence, it finds
39:36
that around about third year of medical education for a lot of learners, we see a decline in
39:41
a sense of altruism and things like that.
39:44
So when I talk about unforgetting compassion, we have to, many of us, I think, have forgotten
39:49
it in some ways.
39:51
And not only do we have to remember it, sort of our origin story, if you will, as you asked
39:56
earlier, but we also have to practice things to help us un-forget it so we don't forget
40:01
it again.
40:03
Because we work in health systems where compassion arguably is not incentivized.
40:09
We work in health systems in places where there's so many external pressures that distract
40:14
us from the person that we are trying to help support and heal.
40:18
Not only do we have to remember, but we have to actively fight against it at times and
40:24
un-forget it and unlearn what we have learned that has actually prevented healing.
40:30
And I think it spirals, I also think of the book Beloved, Toni Morrison's Beloved.
40:34
She talks about this concept of re-memory, not just memory, but re-memory.
40:39
And that's engaging with what memories we may have from our ancestors, from those who
40:44
have gone before, from our experiences, and from the traditions of medicine, of nursing,
40:50
of healing.
40:51
How do we also stay in touch with what has been learned by generations before and honor
40:56
that?
40:57
And don't kick that out of our memory.
41:00
And don't, we have to un-forget and learn skills so we don't forget or re-forget or
41:07
re-forget.
41:09
When we think about our engagement and looking up and the ventral, the cognitive systems
41:16
and what we pay attention to.
41:18
And much of this comes from research by Jim Austin.
41:23
And he's got a book, Zen in the Brain.
41:25
It's a beautiful book.
41:26
It's also a great snoozer if you have trouble sleeping, pick that book up.
41:30
You can use it as a pillow.
41:31
And it's just so dense.
41:32
I'm re-reading chapter over chapter.
41:35
But a lot of this comes from his research where he has found that when we actively look
41:39
upwards, using our ocular muscles to look upwards, we engage what he calls our allocentric
41:46
processing systems, thinking systems, in an allocentric Greek for diverse or other.
41:52
But we engage our brains in sort of taking in the space around us, reading the room,
41:57
paying attention to those around us, what they're giving us, what we're receiving.
42:02
And when we look upwards, we train our brains to kind of engage with that.
42:05
Conversely, his research suggests that when we actively look downwards, we engage different
42:10
parts of our ventral system and different parts of a system in which we are thinking
42:15
more egocentric thoughts, which is not always a bad thing.
42:19
You're studying for your boards, your steps, all of these exams.
42:23
You need to be very egocentric.
42:24
You need to be looking down and memorizing so that you can be a great healer by passing
42:29
all these boards.
42:30
So it's not always a bad thing.
42:31
But when I think about that, and I also think about how great it feels to look up and see
42:36
the shapes of clouds above you.
42:38
How much joy does it feel to see a kite in the air?
42:42
In fact, I had the opportunity to write a children's book about kite flying as it related
42:45
to resilience in the Ebola epidemic.
42:49
Because when we would walk to and from the Ebola units to treat patients, especially
42:54
when walking home after all of the death and suffering we experienced, we'd always see
42:58
healthy kids outside running and flying kites.
43:01
And it felt so good to look up.
43:05
So when we think about unforgetting compassion and going back to our own origins, because
43:12
none of us would be here, no one listening to this podcast, I hope, would be here if
43:17
you weren't inherently a healer and wanting to stay connected with that.
43:21
So maybe that process of unforgetting simply begins by looking up and reminding ourselves
43:26
to look up.
43:28
In this scary world, where do you look most of the time?
43:30
I look most of the time down at my phone, oh, I got a like, I got a, you know, like
43:34
we have to shift that narrative.
43:37
And we can.
43:38
And our brains, I think, and hearts want us to.
43:41
Thank you.
43:43
And just finally, one last thing.
43:44
So you know, working in your role, let's say three years from now, five years from now,
43:50
the office has been incredibly successful.
43:53
You've created a work environment that is sustaining, nurturing, compassionate, committed,
43:59
present, attentive.
44:02
Maybe you can just describe what would that experience be like for a patient coming into
44:06
that system?
44:08
And what would that experience be like for someone working there at whatever level, nurse,
44:13
doctor, receptionist, financial officer, whatever?
44:16
We'll start with the patient.
44:17
We'll move on to the professional and we'll wrap with one of my personal life goals.
44:24
We will see significant reductions in patient harm.
44:28
We will see significant reductions in medication errors.
44:31
We will see significant reductions in, in, in CLABSI, CAUTI, you know, hospital associated
44:38
pneumonias.
44:39
We will see a reduction in length of stay.
44:41
I think we will also see more natural births from mothers.
44:45
I see, I think we will see certain, there'll be certain reductions in length of stay because
44:50
there'll be fewer complications.
44:52
And there might be other longer lengths of stay, which we'll have to negotiate with our
44:56
CFO for maybe a mom who really wants to come in and deliver naturally and we'll have a
45:00
compassionate place where she can do that and safely.
45:05
Of course, we are going to see great, we're going to see great leapfrog scores.
45:08
We're going to see great patient compliments and comments.
45:12
We're going to see patients who say, call in to see a certain physician and that physician
45:19
might be on vacation and the patient will say, I am so glad they're on vacation and
45:24
I trust you with anyone else you're going to schedule me with because I trust so and
45:28
so because they've been my doctor for years, but I know you have such great teams.
45:32
We're going to see patients glow.
45:34
We will see less use of pain medication.
45:39
There was a clown study actually with hospital clowns in a pediatric wards, finding that
45:43
kids that experienced clowns post-op, if the kid welcomed the clown in, there was less
45:48
use of post-op operative pain medications.
45:52
That's what we'll see for patients.
45:53
That's what we're going to see for providers and professionals.
45:55
We are going to see reductions in attrition.
45:58
We are going to see people that show up outside of work hours just to support their teams
46:03
because they love their teams so much.
46:06
We're going to see people that want to work at a place like Emory Healthcare.
46:09
We're not there yet, but this is a dream state.
46:11
We're going to see people that say, I want to work at Emory Healthcare because I know
46:15
you're going to give me two weeks of paid time to volunteer for Doctors Without Borders.
46:19
I know that you see me as a human being and I know that you know the science that says
46:23
when people have time to volunteer in or outside of their profession, they're actually more
46:27
engaged when they come back to work.
46:30
We're going to have people that don't go to work when they're sick and get over that
46:35
hero concept that they have to show up because no one else can do the work.
46:40
We're going to see people picking up extra hours for team members that are sick because
46:44
people know that they matter.
46:47
One term goal for this Office of Wellbeing is that I want to work my way out of a job
46:51
in the next 10 years.
46:53
I think there is a profound irony in that health care needs officers of well-being because
47:01
if truly we are all healers and we come to this profession as healers, then we should
47:06
be the last people on the planet that need well-being support, theoretically.
47:11
I do believe that it is systems that is breaking us, that has broken us, that will continue
47:17
to break us until offices of well-being can better engage with CFOs, CEOs, COOs to really
47:24
shift structure.
47:25
I hope in 10 years there is no place for me.
47:27
Then, Mick, I'll call you asking for a gig.
47:30
Okay.
47:31
Thank you, Tim.
47:33
Thank you so much.
47:34
It's been a great conversation.
47:36
We'll have to have you back at some point and I'm just really appreciative of my friendship
47:43
with you, my collegiality with you, and just you being able to make it today.
47:50
Thank you very much for listening to Flourishing in Medicine.
47:53
We will include a summary of today's podcast and links to Dr. Tim Cunningham and other
47:58
references that were discussed in the show notes.
48:02
I'd like to leave you with a practical exercise to help you flourish during your workday.
48:08
Consider drawing upon this practice or any of the previous ones we have shared with each
48:13
podcast, building a toolbox of practices that will support your well-being and your flourishing.
48:21
This practice involves movement, the kind of movement we engage in regularly.
48:26
But this time now, with awareness, this movement practice is an opportunity to move with intention.
48:32
So either as you're listening to this or after this podcast, walking with intention
48:40
and awareness.
48:41
As Tim described, the clown moves with an intention to show up.
48:45
So here you are just simply walking, showing up to walk, nowhere in particular, but simply
48:52
to walk and be fully with the walking.
48:56
You may want to choose a short lane within your space where you are right now that allows
49:01
half a dozen or so steps in one direction and then simply turning around and walking
49:08
back in the opposite direction.
49:12
Doing this from time to time, spending a few minutes with just walking and consider practicing
49:19
this with awareness and attention, showing up as the clown shows up at work when you're
49:25
moving from here to there in your workplace, at the supermarket, as you walk from your
49:31
car into the house.
49:33
We walk a lot.
49:35
So there's lots of opportunities to turn just short periods of this into an awareness
49:39
practice, bringing awareness to your walking and be curious about what happens.
49:49
So look forward to seeing you next time.
49:51
For more information about EmPRO, who produces this podcast, please visit www.myempro.com.
49:57
And if you'd like to know more about the kind of work I do and the kind of programs
50:06
that I'm involved in, visit www.mickcrasnermd.com or www.mindfulpracticinmedicine.com.
50:20
See you next time.
50:21
Thank you.