Latest / Flourishing in Medicine: From Surviving to Thriving / Flourishing in Medicine: From Surviving to Thriving Episode 5 Christine Runyan, PhD

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Flourishing in Medicine: From Surviving to Thriving Episode 5 Christine Runyan, PhD · Flourishing in Medicine: From Surviving to Thriving

• 0:00
  Welcome to flourishing in medicine from surviving to thriving.
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  I'm your host, Dr. Mick Krasner, and this podcast produced by EmPRO, a medical professional liability
• 0:34
  insurance carrier headquartered in New York State. This podcast is just one of many parts of EmPRO's
• 0:41
  forward thinking peer support activities. I'm so excited to share with you today my conversation
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  with Dr. Christine Tina Runyan, who is a clinical psychologist, previously a professor in the
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  department of family medicine at the University of Massachusetts Medical School, and now with
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  Tend Health, a company she co-founded that provides specialized, private, and accessible
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  mental health care and education to health care professionals and consultation to health care
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  organizations willing to invest in their most precious resource. An expert on health, professional,
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  and especially physician stress, she finds that being valued and finding a place of value within
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  the health care ecosystem is central to being able to sustain energy, quality, motivation,
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  and well-being. Her translation of the effects of stress on us individually and collectively
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  in health care, long a challenge given the nature of the work we do facing into suffering and
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  uncertainty and heightened by the pandemic, helps normalize and appreciate the ways our nervous
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  systems are doing exactly what they are designed to do. And she outlines ways we as individuals and
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  the health care system itself can bring capacities already present online to help restore and recover
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  our well-being. A strong admirer of and advocate for health professionals, I am sure you'll find
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  this discussion with Tina Runyan uplifting. And now, enjoy my conversation with Tina Runyan.
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  Well, welcome Tina. It's really wonderful having you here. You offer so many new and good perspectives
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  and helpful perspectives to health professionals when it comes to flourishing in medicine. So,
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  I like to start this interview with just a question about your story. Mostly it's a question about
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  what got into you to want to be a health professional in the first place? And I say got into you,
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  you know, a lot of us can't help it. It's either through experiences we've had very young, growing
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  up or something that affected us or something during our educational process that really kind
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  of inspired us. And so, what was it for you if you could just share that story of your kind of the
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  origin story of you, Christine Runyan, as a health professional?
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  Yeah, well, first, delighted to be here with you too, Mick. Thank you for the invite and opportunity
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  for this conversation. And for me, in terms of origin story, I can't point to a single moment
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  or event. And I know precisely what you're talking about because I often ask people that I'm
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  work health professionals that I'm working with clinically about their origin story, because I'm
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  always so curious about, you know, whether this was a path they were pursuing from very young or
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  had sort of a crucial incident. And so for me, it was and often it is a single event for people.
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  For me, it wasn't. I think it was a gradual unfolding of wanting to be of service in some way
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  and being sort of perpetually compelled by stories and people's stories. And I actually thought I
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  wanted to be a physician. I started college as a chemistry major. A couple of unfortunate incidents
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  in the lab sort of reminded me that maybe that was not my strength. And I was always drawn to the
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  sort of stories, the human aspect of whatever people were experiencing medically. So there was
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  a book of a compilation of a piece of my mind essays out of the out of JAMA that was in a
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  in a book that I still have on my shelf somewhere when I was I think I read it in college. And so
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  that was sort of the the narrative piece of things and people's relationship with their illness,
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  relationship with their clinicians and their families are sort of going through was what really
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  drew me. So I realized that it wasn't actually the medicine that I was interested in, but the total
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  experience. And so that really led me to clinical psychology and specifically health psychology of
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  that interface between health and illness and people's emotional and psychological and relational
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  experiences with that. As a health psychologist, you know, the public has turned to you as an expert
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  in the psychology of health, of well-being during the pandemic, especially you were called on to
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  comment and help us come to terms with we could say normalize in some way the experiences that we
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  we were having, which we as we collectively as a community, world community in a sense,
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  we're having. And a lot of it relates to this the sequelae of having what you've described as this
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  exquisite stress physiology, exquisite because it's it is beautiful and has kept us alive as a species.
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  So if you could, we're going to shift a little bit because I really think the listeners would like to
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  hear about how this works. Can you walk us through the normalcy of what we've experienced in our
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  bodies and in our minds during the global pandemic? We're going to not stay on the pandemic. Okay.
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  What is the brain and the body trying to do? Why is it doing it? How's it helpful?
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  And how is it challenging to us as well? So I do use that word exquisite in terms of our baked in
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  physiology because it has served us for thousands of years. And I think it really was a common
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  experience that many people have had, but didn't necessarily have language for or connection to
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  until the pandemic occurred. And then we were all sort of very quickly thrust into this shared
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  experience. And so our stress response is is innate to all of us. And it's a very predictable
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  cascade of events when we face something that are sort of the primitive part of our brain
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  assesses to be in excess of what maybe our resources are in the moment or what we can cope
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  with. And that sets off a cascade of things that are really advantageous for us to meet that moment.
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  And that happens at a at a hormonal level, kind of our neuromodulators and down into our physiology.
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  So when we meet in acute stress, our amygdala sort of that fear center in our brain fires and
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  says, Oh, and then sort of we don't have to get to your listeners sort of all probably know all of
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  the anatomical and functional structures. But I mean, essentially, it it sounds the alarm to
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  prepare ourselves to fight or flight flee, or to really sort of shut down or play dead really,
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  sort of to freeze. And so that physiology is is highly advantageous in those moments of acute
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  stress, our heart rate increases, our blood pressure increases, blood is diverted away from
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  our digestive system to our major muscle groups so that we can fight or flee and sort of have
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  increased strength or increased speed, we are there's changes in our immune functioning changes
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  in our, our sweat and preparation, perspiration, our hearing, our visual acuity, all of these
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  things that are really helpful in that acute moment of stress. And so these are these really
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  were pretending increased survival sort of back in the in the day. And, and those are really useful
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  for those really intense moments that we've all probably faced, whether we're driving on the
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  on the highway and need to respond quickly, or really in acute stress events where we have to
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  respond very quickly. But that same physiology happens at much lower levels of threat, and even
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  happen based on a perceived threat or a conjured threat even in our own minds. And so you can get
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  that under the skin reactivity that many people will name really as anxiety, or anxiety, or
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  really as anxiety, or even panic. And, and so in those lower threat events, it's actually not
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  as helpful. And it can feel very distressing and maybe even causing some harms to our body
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  when that is occurring for too long, too intensely, or too frequently, which happens a lot and
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  happened a lot for healthcare professionals during the pandemic. And frankly, I think happens a lot
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  for healthcare professionals, just once you sort of hit the ground clinically, or even probably in
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  in, you know, in medical school with exams, right, this stress response is being activated
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  pretty chronically. And that creates something that we call, you know, an allostatic load where
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  over time, the system is just having to respond with that stress response, again, and again, and
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  again, creating creating sort of a chronic pressure on the nervous system that can't does not have time
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  to recover. It doesn't have time to respond. We have some other facilitative parts of our nervous
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  system, which we can talk about as well to sort of calm that response. But what we found, I think,
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  in the pandemic, and what is true, I think, in many healthcare settings is there's not time or
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  space to actually engage the restorative parts of our nervous system to actually help counterbalance
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  and recover from that ongoing stress response. Yes, you know, I'm glad that you mentioned the
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  part and I'd like to highlight it and actually move toward that about that it's not just from
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  the pandemic in the case of health professionals, but it may be something that's endemic to just
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  being in the health professionals, professions. So if we could just kind of talk a little bit
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  about the unique case, we could say of health professionals, physicians, nurses,
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  mental health workers, etc. And can you, you know, let's talk a little bit more deeply about how the
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  healthcare system long before the pandemic was experiencing these same kinds of effects chronically
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  on its professional staff and other staff, frankly, you know, from that physiologic,
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  neurologic, immunologic, social perspective as well. Yeah, the I mean, I'm fascinated,
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  really by, you know, sort of the the life and work of the health professional, I feel like it's
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  something that's so unique and so different than many other chosen professions. And so people who
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  choose to enter into those professions, again, usually have an origin story, but they also have
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  a drive to care for others to do good in this world to be of service. And that puts them in
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  the arena where they are facing suffering every day and facing a lot of uncertainty as precise as
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  sort of and, and the scientific advancements of medicine have gotten over time, you know, as a
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  as a clinician, I know, as a clinician, you are in the realm of uncertainty, every day. Right?
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  Every every moment. I mean, on occasion, there's things where it's like, Oh, I know, exactly. But
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  there's a lot of uncertainty. And so it's, it's really like no other profession amplified by the
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  pandemic, for sure. But people are facing, you know, every day, every clinical encounter, a lot
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  of uncertainty when when the person or people sitting across from them are suffering in some
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  way. And they're suffering, usually emotionally, physically, often socially, relationally, and
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  sometimes environmentally as well. And there's only so many tools in the toolkit, a health as a
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  single health professional has to address all of that distress. And you are faced with that
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  repeatedly over time, whether you're ambulatory care, inpatient care, for the most part, other than
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  probably well child checks, you know, which are delight. When I worked in primary care, for many,
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  many years, I would always elbow my way into well child checks, just a little, a little a little
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  reprieve and sort of delight in look how many things are going well. But otherwise, it's just
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  continual, facing that that person or people sitting across from you that want answers, want
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  certainty, want a reduction in their pain, distress, often don't want what is happening to be
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  happening. So there's a lot of resistance there to even sort of moving forward. So sometimes it's
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  working on acceptance. And so the health care professional, I think, is faced with and tasked
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  to do a variety of different things that go well beyond what they could handle with just medical
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  and procedural knowledge that is has been historically the focus of their education. And
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  they're sort of missing another strong, I think, component of that, of that stool around, I think
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  there's an improvement around communication around the psychology of illness and how to kind of
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  address that for people and then how to meet their own moments. So that stress response that we
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  talked about is often activated in every encounter. And then you put many, many encounters like that
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  in a single day where then people are, are rushed and they're feeling late and they don't have time.
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  And so for many health care professionals, you have a pretty chronic activation under the skin
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  of that stress response that is not being, that's not being met at all during the day.
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  Yes. And to use kind of the frame that you were talking about earlier having to do with the
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  perception or appraisal and resources. So maybe using that kind of frame, what are some of the
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  elements of what can be done for the health professional short and long term, looking at
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  the domain of appraisal, looking at the domain of the resources, what are some resources that
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  could be built and what are some ways in which we can examine how we are framing that experience?
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  Yeah. Well, it's a, the question sort of leads me to just sort of, I think state something that is
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  very ubiquitous in this space around flourishing in medicine and kind of the issues of burnout and
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  the quote unquote system drivers of burnout and how some of the resources really are in many ways
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  the responsibility of the organization and the health care system to fortify our health care
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  professionals with adequate resources, whether that is through staffing, through sort of assistance
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  with the electronic medical record and sort of managing the inbox, whether that's with scheduling,
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  all of the things that ultimately come down to sort of how we pay for those resources. So I just
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  want to call that out, but I think what your question is really about is sort of what are the
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  intra and interpersonal resources that people can learn, can lean on, can call upon to help them meet
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  those moments as a healthcare professional. And this is very much where, obviously this is my line
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  of sight as a psychologist, but where I think sometimes we do a disservice when we get too
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  dichotomous around, it has to be the system folks fix. And my experience in working with a lot of
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  distress healthcare professionals is that fix has, the promise of that fix has been coming for a
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  long time, right? It's just around the corner, keep going, we're going to get there. And it works at
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  a fairly glacial pace. And there's a lot of perverse incentives that are maintaining the status
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  quo. And so while I am very much in support of a lot of those systems, fixing those systems drivers,
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  in the meantime, we have a lot of people who are suffering. And so I think your question, you know,
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  sort of is really about those intra and interpersonal resources. And so one of the core ones, I think,
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  is really around learning about and appreciating that inside of all of us, we actually have an
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  innate resource to calm our own bodies, and that we can meet those moments of increased stress
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  through our own capacities. In fact, through our own wiring of our nervous system that has this
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  counterbalance the parasympathetic nervous system, countering that fight, flight or freeze
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  sympathetic nervous system, and that we can learn very specific skills, often that are really in the
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  moment skills, including, you know, various breathing techniques, self compassion techniques
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  that can calm what's happening underneath the skin to help people really be more present and meet the
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  moment that's called that's called for. And then you can do that intra personally. And then I think
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  there are these interpersonal aspects that can help us to the affiliative part of our nervous system,
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  the tendon befriend part of our nervous system that also is wired, can be leveraged through sharing
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  stories through connection through not holding all of the fear and burdens alone, right, is sort of
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  sharing, having somebody hold some of that with you being able to share about a mistake. This is
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  something that I talk with people a lot because the culture does not have a lot of space for helping
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  people to share and learn from mistakes as much as tuck them away, which really, it cuts off the
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  learning. It cuts off the learning in a way that doesn't is an advantageous for the health care
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  professional or for you know, for their patients. So, so that interpersonal part can activate that
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  tendon befriend you get sort of good release of oxytocin and dopamine and serotonin and sort of
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  that feels it we all know what that's like, you know, sort of it feels better. And those are
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  resources that our organizations can provide time and space for, for us to have some of that sharing,
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  but we also have that internal resource if we if we want to leverage that kind of on the regular
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  minute by minute in our work. Well, I'd like to get in a moment to some of those specific things
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  that you just kind of covered a little bit. But before we do that, I want to actually turn towards
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  sort of an appreciation for the health professional themselves and what they what they already bring
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  in with them. Can you name or maybe just think with me about what are some of the qualities that are
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  already present in the health professionals by virtue of their path, the decisions they made
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  and who they are because they're kind of a unique, there's a unique mold like you described that
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  brought them to that and how that can be leveraged and how to bring those online. So in the work that
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  I do, and and and I did a lot of education and training kind of for for health care professionals,
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  physicians in particular, and now I sort of work more exclusively in caring for people who
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  physicians who have some level of distress, but I would say ubiquitously across sort of the
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  the distress group that I see now and and those who seem to be, you know, thriving in some way
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  that, you know, there is a curiosity for sure that I think brings people to medicine.
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  There is a deep love of learning. And so that that interest in seeing knowledge as as power,
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  but power to be used for good and for others, I think is pretty common. There is often a high
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  level of conscientiousness can border on sometimes sort of obsessiveness, which the system is happy
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  to exploit. But that sense of conscientiousness, I think, is makes people really good on this path
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  of becoming a physician and a deep capacity for for empathy. They care about the suffering for
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  others and empathy is, you know, it's a it's, it's often it's a clinical empathy in medicine is,
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  it's, it's tricky, because it can actually increase suffering. Because when people are really
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  feeling alongside someone else, their emotional empathy, in addition to their kind of cognitive
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  empathy is really high. And they are taking that on, which when we look kind of at using some
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  physiological measures, and even some functional MRI measures, it looks like they are suffering in
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  the same way that the person they're empathizing with is suffering. And so it can that level of
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  empathetic distress, actually, if not leveraged towards compassion, which is a desire both
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  witnessing that suffering, caring about that suffering, but a desire to alleviate it, and
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  really that very slight u turn towards wanting to alleviate it, but not holding the suffering. And
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  so I think they a lot of people come with a deep level of empathy. And this the training is really
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  around how do you teach that slight u turn towards compassion, so people don't get overburdened by
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  the empathetic distress, you know, when I think about sort of the big five sort of first personality
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  factors, kind of the ocean, you know, I think there's, there's often a high level of openness
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  among clinicians. And that sort of dovetails with with curiosity, sometimes I think those get shut
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  down a little bit through the through the educational process where the learning is so directed and
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  sort of plumbing learning instead of an openness for curiosity, and the time constraints and kind
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  of all the other factors start to prune a little bit at that curiosity and people's innate reasons
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  for going and desires of going into medicine. But I think it's sort of a core personality level that
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  characterizes a lot of who chooses to go into medicine. Yes, thank you. You know, and I now I
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  want to come back to some of the specifics, you know, I completely agree with you. And I'm a strong
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  advocate in the teaching I do about the systemic drivers being really part of a large part, the
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  large part, just like in errors, it's the, you know, systemic drivers that really create conditions
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  in which errors occur, not necessarily some individual fault. And I think the last thing we
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  want to do, I agree with you, Christine, still tell our health professionals that there's something
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  wrong with them that they're not resilient enough, and that they have to, you know, learn some skill
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  because they're, they're just deficient. So that's the wrong message. On the other hand, I like to
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  quote Suzuki Roshi, one of the real famous Zen teachers who said something like, you're already
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  perfect. And you could use a little improvement, you know. So what are some of the things we can
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  do specific things to help meet the challenges that we have as health professionals, especially
• 23:49
  when we're feeling overwhelmed with responsibilities, tasks, as well as feeling a lack of control, which
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  is a lot of it, we have all this responsibility, very little control. And also, we let's just expand
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  that maybe it's maybe a little challenging, but can you also counter that with what health systems
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  can do to support their staff while also addressing some of these fundamental dynamics that contribute
• 24:13
  to the challenges that they're facing? Yeah. So one place that I work, a couple sort of core places
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  that I work a lot that I'll highlight here around organizations and sort of then dive into the
• 24:27
  individual is, you know, when people feel valued by their organization, that seems to mitigate
• 24:35
  burnout. And that's a little different than values alignment. So that is one thing that I that I look
• 24:41
  out with a lot of people that I talk with is, is identifying their values and how well their values
• 24:47
  align for the institution that they're working in, because sometimes people will conflate sort of
• 24:53
  medicine or health care as being sort of the problem. And sometimes it's just a misalignment of values
• 25:00
  with their particular organization or leadership. That doesn't mean they have to sort of quit being
• 25:05
  a clinician, which is where often people will go to is I can't do this work anymore, as opposed to
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  is there a values alignment with your particular organization, which really starts with an
• 25:15
  identification of the personal values. And sometimes that is like really going back to the to the to
• 25:20
  their roots and sort of their their why their reason for going into medicine. But when people
• 25:26
  have the subjective feeling of being valued by their organization, that tends to mitigate burnout.
• 25:32
  Now that means different things to different people. And so at an organizational level, sort of in
• 25:39
  addition to kind of those core things around control, autonomy, workload is exploring for their
• 25:49
  health care workforce, what would it mean to be valued. And I think that is really a bottom up
• 25:54
  proposition because oftentimes, you know, we saw this a lot during the pandemic, you know, people
• 25:59
  were were valued by, you know, coffee and pizza. And while that may have been sort of helpful to
• 26:07
  meet a very basic biological need, I also on the heels of that heard a lot of resentment. And
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  resentment is a key theme that I hear from clinicians and physicians and training and
• 26:19
  training and physicians. And there are some unique ways in which that resentment coming out of
• 26:24
  training sort of plays out into the cultural status quo of medicine, I think. So for organizations,
• 26:32
  really trying to understand not just the scope and nature of the problem, but really what is going to
• 26:40
  help these this particular group of clinicians feel valued. And so I and I think there's some
• 26:47
  nuance based on settings, based on geography based on demographics, I think, you know, there,
• 26:54
  there's people at the seasons of their career in medicine, where different things are going to be
• 27:00
  valued when people have very little margin in their life, because they have a two, you know,
• 27:05
  two career household with young kids and very little margin, what is going to help them feel
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  valued is going to be very different than somebody in their first maybe three years of practice or
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  somebody who is, you know, at has older, maybe older kids or doesn't have kids and is at their
• 27:24
  20th year of practice. And so that's not a one size fits all solution. But I think there are
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  answers there if the organization really does query kind of how to feel valued at the, you know,
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  and at the individual level, what I often hear when I ask people about what is, tell me about
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  a time where you, you know, felt really valued, tell me about a time when you were reconnected
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  to your why and this was meaningful to you, almost always, it's about the relationships
• 27:57
  with their patients. And almost always, it's about having enough sort of space, which sometimes
• 28:04
  translates to time, but not always to have the kinds of interactions that remind them about
• 28:12
  why they chose this profession and why they chose this particular specialty. And that actually
• 28:18
  penetrates so deeply into sustaining them in this really difficult work. Yeah, that's really, really
• 28:26
  helpful. I wanted to talk a little bit about the connection between being valued as you discuss
• 28:33
  and something you mentioned earlier, cooperation, connection, feeling tended to as an undergirding
• 28:40
  of both individual assets, but also the positive functioning of a healthy healthcare team, healthy
• 28:47
  healthcare organization, a healthier healthcare system, those parts of that affiliative stress
• 28:53
  response that you alluded to, maybe you can connect the dots for us and feeling valued.
• 28:58
  Could it be a frame that we individually and our organizations can look at when in thinking about
• 29:04
  how to design a more workable environment? Yeah, I guess that there's this very specific example
• 29:12
  that comes to mind from that question is, you know, your listeners will be very familiar with
• 29:17
  in medicine, the, you know, doing M&M conference, morbidity and mortality conference, right? We,
• 29:23
  we, we excruciatingly sometimes sort of pick apart the things that go wrong. And while it's not done
• 29:30
  in a way to point fingers or to blame, but presumably to sort of prevent those things
• 29:34
  from happening in the future. And this is, this is, this is not an indictment of medicine in
• 29:40
  particular, because I think a lot of the health helping professions that are very focused on sort
• 29:44
  of finding and fixing the problem, we historically, and I think systemically turn a blind eye to
• 29:52
  what's working well. We don't have forums where we highlight and celebrate collectively, something
• 30:02
  that worked really well, and not how do we try to backfill and fix the thing that went wrong,
• 30:08
  right? Like after this, somebody tried to go through TSA through, through an airport with a
• 30:14
  bomb in their shoe. Now we all have to take off our shoes at the airport, right? Like it sort of
• 30:18
  felt like let's try to find that particular loophole and we're going to solve for that. But
• 30:23
  to say like, what is, what are some instances where things went exceedingly well and the system
• 30:30
  was tight and worked and the handoffs were good and people felt cared for? And these are the things
• 30:35
  we might celebrate on sort of patient satisfaction, you know, reporting, but sometimes they don't
• 30:40
  always mirror what the team feels like really went well. So, you know, might we have opportunities
• 30:47
  individually and collectively to look at the bright spots and to celebrate those and learn
• 30:53
  from those and amplify those that actually helps collectively activate that, you know,
• 31:00
  that tend and befriend response. And it's what I actually, you know, will ask people about and
• 31:07
  encourage people to do even as an individual practice is sort of what went well today?
• 31:12
  What did I learn today? Because our minds are so we have a negativity bias that is baked into all
• 31:18
  of us as humans to find and fixate on the thing that we don't, that we want to be different that
• 31:25
  we don't like that we don't like about ourselves. And we fail to recognize all of the small and big
• 31:31
  ways in which we show up. And we do really, really well for ourselves and for our patients. And that
• 31:38
  becomes the norm, the expectation. So anything less than that is seen as a mistake or a failure.
• 31:46
  And so I think as a system, as an organization, and then just, you know, as an individual system,
• 31:53
  we can sort of start with ourselves to start to highlight those those wins.
• 31:57
  Yeah, that's really refreshing. I'm thinking of to get there, you know, it isn't just doesn't just
• 32:03
  happen. And the literature on teamwork is pretty clear about two main factors that really support
• 32:10
  healthy team functioning, which is communication, actually, the quantity of communication correlates
• 32:15
  with quality, which is really fascinating, as well as the element of psychological safety. Those are
• 32:21
  two actually very connected things. So in order to have an environment in which you can safely and
• 32:29
  you can safely and not self consciously talk about what went well, you have to also create
• 32:36
  an environment where there's a lot of communication going on at every level of team, let's say, or
• 32:41
  every level of the organization, as well as a safety, you know, feeling like you're not going
• 32:46
  to be stigmatized or it's okay, you're supported in telling your story about what really what really
• 32:53
  went well. The psychological safety as a, you know, as a team and as an organization, I think we,
• 33:01
  one of the challenges, I think, in a lot of particularly hospital based settings,
• 33:06
  different from ambulatory settings is there's so much rapid shifting of who that team is on any
• 33:12
  given day, sort of a week, and particularly in training settings, you have people coming through.
• 33:18
  And so there's not a lot of there, the team is not static. And so there is a fragility in that,
• 33:24
  I think, often in terms of people having to constantly adjust to a new group of players
• 33:30
  and dynamics and personalities. And so that actually can weigh on psychological safety
• 33:35
  quite a bit. I would it be okay if I read a short poem? I would love that. That would be
• 33:41
  fabulous. So this is when I think about this with medical providers, it's a poem by Rudy Francisco
• 33:48
  entitled instructions. And he says, gather your mistakes, rinse them with honesty and self
• 33:58
  reflection. Let them dry until you can see every choice. And the regret becomes brittle.
• 34:06
  Cover the entire surface in forgiveness. Remind yourself that you are human and this too is a
• 34:14
  gift. It's really it's so honest and authentic. And it doesn't deny, you know, that there's,
• 34:23
  we're not perfect. But it also in some ways celebrates we're not perfect, too. Right?
• 34:28
  Yes. Yes. Yes. And that's where I, there's the covering up the sort of denial,
• 34:35
  the sort of denying it, it robs us of the opportunity to to be fully human. And to
• 34:42
  truly learn from that. So this idea of, you know, let them dry until you can see every,
• 34:48
  you know, every, every choice. But the the piece that is often missing is that self compassion,
• 34:56
  right? Cover it in forgiveness. Yeah. And I think that is, that's the psychological safety
• 35:03
  to be able to do that. And the psychological resilience to carry that forward. That is how
• 35:11
  we learn not from not from beating ourselves up over and over again and expecting perfection.
• 35:18
  I agree with you, physicians are among the most resilient group of individuals they've had to be,
• 35:25
  they've learned to be and and sometimes that comes with the with that self critical edge
• 35:32
  that has propelled them. And sometimes, you know, there's a little resistance to giving that up
• 35:37
  because there's some fear that they won't continue to learn and grow and be as good.
• 35:43
  And so that's a little dance. And I work with people a lot on the ways in which that critical
• 35:50
  voice has served them, the ways in which it hasn't and what might it be like to bring some
• 35:57
  internal psychological safety, some kindness and how might that actually really ripen the conditions
• 36:04
  for learning and growth? Beautifully said. Thank you. Yeah. I'd like to shift a little bit because
• 36:10
  I'm really what you've done and the choices you've made in the recent years in your life have really
• 36:17
  shown that, you know, what's at your heart and what's really important to you, you've actually,
• 36:22
  with whatever risk is involved, you know, went and pursued that. So I'd like you to talk about
• 36:28
  TEND Health, T-E-N-D Health, what it is and what's your vision and how's it going? Yeah. Oh, great.
• 36:36
  I thank you so much for the opportunity to talk about TEND and just the preamble to that to say
• 36:43
  that I made a really significant shift in going to TEND and had many moments of meeting my own fears
• 36:50
  my own doubts. It was a very risky proposition. So in 2020, I co-founded TEND Health with Joan
• 36:58
  Fleischman, who is also a clinical psychologist. Both of us were in academic medical environments
• 37:05
  and very close to sort of the training of medical students and residents and fellows and
• 37:11
  working in primary care environments for many years alongside our physician and nurse colleagues.
• 37:16
  And for me, really seeing a very predictable arc of enthusiasm and empathy and compassion and
• 37:27
  brilliance have a very predictable arc through training and through early years of practice that
• 37:35
  really made it unsustainable for many people. And it really sparked a curiosity in me as sort of
• 37:41
  what's going on that people are burning out and becoming resentful and for many people
• 37:47
  sort of what I call hosting their own private protest against medicine in ways that might show
• 37:54
  up as relationship problems or drinking too much or playing too many video games or things that
• 38:00
  sort of in privately they were protesting to sort of claw back some kind of agency or time or
• 38:08
  connection with something important to them that ultimately didn't serve them very well, but was
• 38:12
  sort of a short-sighted attempt to try to meet the stress of medicine. And so I got really interested
• 38:20
  at that point in curriculum development and thinking about how my perspective and the skills
• 38:25
  that I have as a psychologist might be advantageous for residents and fellows, particularly in family
• 38:32
  medicine. And then as I started doing this throughout the institution with other disciplines,
• 38:39
  I realized how devoid of that perspective many other disciplines were and how many mental health
• 38:46
  needs were going unmet. And so I saw the rising of the numbers in terms of burnout and in terms of
• 38:55
  anxiety and depression and physicians. And so wanted to solve for that problem in a way that
• 39:02
  I felt like hit many of the pain points. So Tend Health is a company that is exclusively dedicated
• 39:07
  to caring for the mental health and wellbeing of healthcare professionals. And we started in,
• 39:14
  we are a fully telehealth platform for mental health care, kind of full continued mental health
• 39:20
  care coaching, counseling, medication management, and so forth. And so I was very excited to be
• 39:25
  able to do that. And so I started to do a lot of care for mental health care, mental health care,
• 39:31
  mental health care management, individual offerings and group offerings. And we started in the five
• 39:35
  states where my co-founder and I were licensed and we've grown now to be able to provide care
• 39:40
  in 44 states. And we have a model of care where we try to create something that's outside of the
• 39:48
  four physicians in particular, although we see any healthcare professional. It is paid for often by the organization.
• 39:55
  So we contract with organizations so that whoever is identified is kind of eligible,
• 40:00
  whether that's the residents or fellows through GME or their medical staff, it's free to them.
• 40:06
  And they can access it with a couple of clicks. We have now 35 psychologists on our team, all of
• 40:14
  which who have cultural competence in caring for healthcare professionals, either because they
• 40:19
  have worked or worked in medical schools or training environments or have a specialization
• 40:24
  in caring for this population. So we really ensure that if you come to see one of our clinicians,
• 40:28
  they're going to get your world a little bit in addition to sort of what they bring as far as their
• 40:33
  skillset in terms of psychological intervention. And because we're not billing insurance, because
• 40:39
  this is paid for by the organization, which by the way, I always say is, you know, is a way that an
• 40:45
  organization can say that they value their workforce. They can't make the work less hard,
• 40:51
  but they can offer this as a way that they see what people might be experiencing. And they want
• 40:57
  a safe place for them to go talk, whether it's one time about a bad outcome or whether it's an
• 41:02
  ongoing episode of care. It is a way organizations can value their workforce. But because we're not
• 41:08
  billing insurance, it really frees us up from having to diagnose or pathologize in cases where
• 41:15
  it is really just the endemic stress of being a physician that is resulting in whether it's
• 41:22
  burnout or other kinds of mental health sequelae, because we don't have to sort of say you have this
• 41:27
  diagnosis to justify getting paid for our service. That also really protects the physician's
• 41:34
  credentialing and licensing and even underwriting for disability insurance or life insurance,
• 41:40
  because we don't have to fabricate a diagnosis to get paid. So when they're asked the question,
• 41:47
  right, have you been diagnosed with a mental health condition, you might have seen a clinician or a
• 41:53
  practitioner for care, but our hand is not forced to diagnose you to get paid. So we've tried to
• 41:58
  create a model of care that really creates that psychological safety for physicians to access care
• 42:06
  and do so in a way that their institution supports and honors, while not giving any feedback
• 42:12
  or direct anything, any feedback that the organization gets is all anonymized,
• 42:17
  de-identified, just so they know the service is being used. It's a wonderful and new model
• 42:23
  in a sense of care. One of the things I've really appreciated about when you speak about depression
• 42:29
  anxiety in this population, you usually couch it in language of symptomatology and not pathology,
• 42:36
  and I think that's so helpful. And so many of our colleagues, you know, do have legitimate worries
• 42:42
  about their licensure, about their ability to stay in the work. And so this is just a wonderful way
• 42:47
  of doing this. So going to include the information in the show notes so those who want to learn more
• 42:54
  about it can do so. I just have about two more questions somewhat related in a way, I guess.
• 43:02
  The first is, maybe you could just talk about, when you speak, there's just this joy and you
• 43:10
  exude just pleasure in being in this world. And I'd like you to talk maybe a little bit about
• 43:16
  the importance of joy and meaning in our medical work. Why is it important? Do you think it's
• 43:22
  important? I'm assuming you do, but maybe I need to ask the question, do you think it's important?
• 43:26
  And why? Yeah, I mean, for me, it probably goes back to your very first question, sort of on
• 43:36
  the origin story, sort of why am I here, sort of in a specific and kind of esoteric way.
• 43:45
  Like, what is my purpose? Why am I here? And I derive a lot of joy from feeling like I am
• 43:54
  being of service to people in a particular way and using what I think are my particular interest
• 44:03
  and maybe gifts or proclivities to be of service in that way. And that for me is around connection
• 44:10
  and bearing witness and being able to hear stories that nobody else wants to hear, to sit with people
• 44:21
  in their uncertainty, in their suffering, and try to discern sort of what is my role to play in this
• 44:30
  moment, knowing there are most things I cannot fix. And I learned that long ago and, you know,
• 44:38
  there's a freedom in not trying to fix. And there's a freedom in what I hope I convey also is,
• 44:48
  I don't see people as broken. There is actually nothing to fix. And so it's not just that I'm
• 44:54
  like, I can't fix that. I'm out. But like, this is part of all of it. And through my own experiences
• 45:03
  and hardship, really knowing that when we can be really honest and authentic about our own struggles,
• 45:12
  and even for me, sort of talking about the initial, this starting 10th health, so many moments of deep
• 45:19
  fear and uncertainty and noticing this part of me that wanted to scramble to safety, just give me,
• 45:26
  just give me, you know, this, this feels so risky, and having the capacity to name that and sit with
• 45:33
  it and sort of trust that my passion in this will carry, will sort of will carry me through,
• 45:41
  my value in this will carry me through. And so I know that my own experiences come to bear when
• 45:48
  I sit with people in that way, as I know that theirs and their willingness to to go deep in that
• 45:58
  always makes them a better physician, always makes them a better clinician. And so that brings me a
• 46:04
  lot of joy. Because I feel like it's, you know, it's, I know, I work a lot at the individual level,
• 46:11
  but ultimately, systems are comprised of individuals. And so it's my small part to
• 46:16
  make the healthcare system better. So would you be willing to maybe just share a brief
• 46:21
  story of something that you experienced relative to this work you're doing now that was just
• 46:27
  particularly meaningful, doesn't have to be the most meaningful thing, but just something that
• 46:32
  gives a little sense of how you derive meaning. Oh, so many. Yeah, I mean, I have many, many moments
• 46:41
  where, you know, well, where I will get the kind of feedback from somebody that acknowledges that
• 46:49
  through our work together, they they have chosen to stay in medicine, and have done so with a rebirth
• 47:01
  of, of passion, and of importance, and and sort of meaning in their work. And maybe it looks slightly
• 47:08
  different than when they went than when we started. But yeah, I'm sort of a sort of thinking of like
• 47:15
  several people, and they're kind of the amalgam together of a lot of times it comes from people
• 47:22
  re discovering the need and importance for their own boundaries to sustain them in this work in the
• 47:33
  way that they show up best. And so again, maybe it looks slightly different. But I always feel like
• 47:40
  it's a win when people choose to stay in this practice that they dedicated so much time and
• 47:49
  money and energy to do, even if it even if it looks slightly slightly different. Great. Thank you.
• 47:56
  Okay. And finally, what do you like to do for fun and enjoyment? And don't worry if your answer has
• 48:02
  something to do with the work that you do, because, you know, it sounds like that's really enjoyable,
• 48:07
  but it could be something else. We just want to hear a little bit about that. Yeah. So I would
• 48:13
  say for me, one of the most joyful things is is through movement. And I'm obviously a health
• 48:21
  psychologist have always had interest in sort of the mind body connection and the body as a source,
• 48:27
  a deep source of information, but also resource. So for me, a lot of my joy comes in things that
• 48:35
  are in movement with yoga, I really love to hike. And so you have this combination of movement in
• 48:41
  nature and the experience of awe, which, you know, is is sort of right up there is sort of peak
• 48:47
  experience for me. I love to read nonfiction and fiction. I like to listen to music, I like to go
• 48:55
  to see live music. And what else I like to cook. Lovely. What else do I like to do? I like to, you
• 49:03
  know, I like to meditate and be with people who are interested in exploring their inner, inner world.
• 49:10
  I'm taking a class on the Enneagram right now, which I find fascinating by this woman who is
• 49:16
  90 years old, and who has this deep well of knowledge about the Enneagram and articulation
• 49:24
  of those concepts in in practice that I just is it's inspiring and I'm in awe of her. So that's fun.
• 49:34
  Lovely. Well, there's a lot. Thank you. Is there anything else, Tina, that you'd like to
• 49:39
  just share with our audience? As we finish up here?
• 49:43
  I think what I would like to share is just my deep gratitude. And while I don't know everybody
• 49:50
  who's listening to this podcast, there is a commonality and a universality at some level
• 49:56
  in the story of what drives people to caring for others. And it's it's beautiful and it's honorable.
• 50:03
  And I always say that I think our clinicians are the most precious resource in our health care
• 50:10
  ecosystem. And so I honor each one of you and am deeply grateful for the work that you do.
• 50:17
  Thank you. Thanks for listening. We will include a summary of today's podcast and links to Christine
• 50:25
  Runyan and other references that were discussed in the show notes. I would like to conclude today's
• 50:31
  podcast with a practical exercise to help you flourish during your workday. The intention is
• 50:37
  for you to add this to the toolbox of skills that you can draw upon to enhance purpose, meaning,
• 50:44
  and well-being. Given what we know about our acute stress response and how, as was discussed
• 50:49
  in the interview today, the cognitive and emotional appraisal of events can begin that cascade,
• 50:55
  today's simple practice is designed to bypass that cognitive and emotional circuit
• 51:02
  by directing our attention somatically. A well-known practice, this is called Where Are My Feet?
• 51:09
  Some of you may have done it before, and it can be called upon when one notices the earliest signs
• 51:14
  of anxiety or other kinds of distress. When needed or desired, simply bring your awareness
• 51:21
  to your feet. You may want to try this right now just to practice, asking yourself, where are my
• 51:26
  feet? What am I feeling right now in my feet? And dwelling there for as long as you would like,
• 51:34
  a few breaths, longer. Noticing as you direct your attention to your feet, all that other stuff,
• 51:42
  the cognitions, emotions, stories, other sensations, although still there, have taken at least
• 51:48
  temporarily a backseat to simply investigating sensations in the feet. You can try this anytime,
• 51:57
  practice, you can call upon it when you were in that early or even later stage of your life,
• 52:03
  or even later stages of distress or anxiety. I hope you found this podcast and the simple exercise
• 52:11
  I just shared with you useful, and I look forward to having you join us for our next episode of
• 52:17
  Flourishing in Medicine, From Surviving to Thriving. If you'd like to learn more about
• 52:23
  EmPRO, please visit www.myempro.com. And for more information about me and my work, please visit
• 52:33
  either www.mickkrasnermd.com or www.mindfulpracticeinmedicine.com. Thanks for joining us.
• 53:03
  Thank you.