Latest / Flourishing in Medicine: From Surviving to Thriving / Flourishing in Medicine: From Surviving to Thriving Episode 22 Navigating Medicine: A Surgeon's Journey of Advocacy and Empowerment with Dr. Carter Lebares

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Flourishing in Medicine: From Surviving to Thriving Episode 22 Navigating Medicine: A Surgeon's Journey of Advocacy and Empowerment with Dr. Carter Lebares · Flourishing in Medicine: From Surviving to Thriving

0:00
If we lose human beings who are willing to sacrifice
0:04
a tremendous amount of years, personal life,
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personal gain, as well as just physical wellbeing
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on a day -to -day basis, not eating, not peeing,
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not sleeping, in order to take care of strangers,
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in order to be drawn to a vocation that requires
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them to sacrifice their own wellbeing at times
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to take care of strangers. If we lose that, which
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is what medicine currently represents in our
0:33
civilization, we're losing a pillar of civilization.
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So it's not a small issue. It's not about doctors
0:40
wanting to be paid more. It's not about people
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wanting to pass the buck and point the finger
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when we're all in a difficult situation together.
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We're talking about really fighting for something
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that is irreplaceable if we lose it. And that's
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individuals who are willing to go into this work.
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Welcome to Flourishing in Medicine from Surviving
1:02
to Thriving. This is your host, Dr. Mick Krasner,
1:05
and this podcast is produced by EmPRO, a medical
1:09
professional liability insurance carrier headquartered
1:11
in New York State, committed through its peer
1:14
support programs to supporting physicians. The
1:17
title of today's podcast is Navigating Medicine,
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a Surgeon's Journey of Advocacy and Empowerment
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with Dr. Carter Labares. Dr. Labares is an Associate
1:28
Professor of Surgery in the Division of General
1:30
Surgery and the Director of the Center for Mindfulness
1:34
in Surgery at the University of California, San
1:37
Francisco. Her research interests include resilience
1:41
and mindfulness in surgery and the neuroendocrine
1:45
and cognitive effects of stress of learning and
1:48
performance. She's developed, studied, and published
1:51
extensively on a customized curriculum specifically
1:53
designed for surgeons, Stress Resilience Training,
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ESRT, which has been demonstrated to improve
2:02
burnout and global executive function, among
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other effects. In our conversation, Carter shares
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her passion for advocacy, advocating for disadvantaged
2:13
youth, and her journey from biochemistry to pursue
2:16
a career as an academic surgeon. Throughout her
2:20
career, she's focused on improving the surgical
2:22
training environment advocating for change and
2:25
addressing systemic challenges in health care.
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Her development of ESRT and her powerful and
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deeply committed advocacy work appear integrated
2:35
into a life where she expresses the values of
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supporting and caring for others and a recognition
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of the simplicity of our moments, whether with
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colleagues, trainees, family, friends, and community,
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including the natural world. And now, enjoy my
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conversation. with Dr. Carter Lebares. Welcome,
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Dr. Lebares, to Flourishing in Medicine from
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Surviving to Thriving. Thanks for having me.
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I'm glad to be here. So what I'd like to start
3:06
with is, and I have started most of these recordings
3:10
with other guests in a similar way, is listening
3:14
to you about your story of how you got into medicine.
3:16
I know for you, it was kind of a little bit of
3:19
a circuitous or at least a long, lengthy path.
3:23
And in particular, if you could kind of think
3:25
back to some of the early, maybe they weren't
3:29
so early, whatever the influences were that motivated
3:32
you, because it's quite a grueling and challenging
3:35
and lengthy path to enter medicine, and especially
3:39
the surgical specialty. So what was it, something
3:42
in your childhood, something in your work life,
3:44
something along the educational journey that
3:47
really made sense to you that you wanted to do
3:50
this? It actually did not have much to do with
3:55
my education or being exposed to, say, positions
4:01
as I was growing up. After I moved out of my
4:04
parents' home and I went to live independently
4:06
in Minneapolis, where I grew up, I lived in a
4:09
neighborhood that was really mixed socioeconomically
4:13
and lived next door to four kids who I became
4:18
kind of an informal guardian for. They had parents
4:22
who were lovely and very diligent caretakers.
4:26
But just like every kid everywhere, having some
4:30
extra help was a good thing. So that was sort
4:33
of where I came in. These kids were young when
4:36
I met them, between the ages of like six and
4:38
ten. And I knew them over many years. And I watched
4:44
them and their friends and the kids around them.
4:48
just have this increasingly started future that
4:54
did not at all reflect the promise and aspiration
4:59
and dreams that I knew them to have as little
5:01
kids. And it was very disturbing to me. Hand
5:07
in hand with that was living right next door
5:10
to and in the midst of their experience of poverty.
5:14
And that was really appalling to me. in such
5:18
a wealthy country with some individuals who are
5:21
just exceedingly, exceedingly rich to see people
5:24
who were fighting over food. Fast forward, I
5:28
met my husband and moved to California. I was
5:31
working as a biochemist. My job was interesting.
5:35
I learned a lot, but it didn't necessitate me
5:38
spending all of my waking hours on it. So I had
5:41
a lot of waking hours to think more strategically
5:44
about how I might help these kids, how I might
5:48
figure out a way to empower them with skills
5:52
inside of themselves so that they could create
5:56
some change in their outlook, in their future,
6:00
that the systems and the culture might take generations
6:05
to catch up with. And so I read a lot of the
6:08
literature. I was trained in undergraduate as
6:11
a biochemist, and I was really comfortable with
6:14
reading about scientific research. And so I just
6:18
searched everywhere for programs or interventions
6:22
that might pertain to this. And there weren't
6:25
very many, if any. And at a certain point, I
6:28
came to see that I needed more education in order
6:33
to have more leverage on this issue. And I was
6:37
working in a startup, a biotech startup in the
6:40
Bay Area. And those are really wonderful environments
6:43
because there are really no walls between the
6:46
most senior people, the C -suite, and the most
6:50
junior people who are like running the experiments.
6:53
And so I went to all of the walks, professional
6:57
walks that were represented there, lawyers, public
7:00
health advocates, physicians, scientists, the
7:04
CEO, and said, if you could do it all over again,
7:07
what? advanced education would you aim for? And
7:11
again and again, they said a physician, because
7:14
you can be an advocate, you can fix things hands
7:16
-on, you can impact individuals, you can change
7:19
systems. And so that's how I decided I needed
7:23
to go into medicine. So that's a really incredible
7:27
story. And I'd like to just underneath that a
7:31
little bit has something to do with this impulse.
7:34
that comes out of caring this impulse to take
7:37
care in this case your neighbors and these children
7:39
of course who you could project forward and wonder
7:43
about you know what kind of future they had but
7:45
also this uh desire to be an advocate for them
7:49
and for people like them what was it about you
7:52
what how how did you have those qualities of
7:56
caring what do you know anything about What were
7:59
the antecedents to that part, that desire to
8:02
care, that desire to advocate, and that desire
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to take a leadership role in a sense like doing
8:07
something about it? Well, I think I've always
8:12
hated bullies and injustice, even when I was
8:16
a little kid. My mom would tell me that on the
8:19
playground, the fights I would get into weren't
8:22
about necessarily someone having an issue with
8:25
me or vice versa. but me observing someone being
8:29
cruel or unfair to another person. And I was
8:34
born 10 pounds. I'm, you know, I'm actually a
8:37
normal sized adult now, but I was always like
8:39
a big kind of tough kid and I would weigh in
8:43
swinging to defend people. And I've felt like
8:48
that all my life. And on top of it, I'm incredibly,
8:51
incredibly privileged. You know, my, my dad came
8:54
out of The depression, he was orphaned as a kid
8:58
for some time, kind of scrabbled on the street
9:01
just to get food for his family. My mom had similar
9:05
hardships. You know, her mom was widowed in the
9:08
50s or late 40s, actually early 40s. And so they
9:12
really understood about being working class,
9:14
about having potential and promise, but having
9:17
no opportunity. And so I was really raised to
9:21
respect that everyone has gifts. And it's more
9:27
often than not circumstance that decides if they
9:30
have a chance to share those or not. And I felt
9:35
that that kind of injustice sucks. And this just
9:39
seemed like one small way that I could help.
9:43
So maybe connect the dots for us. I'm kind of
9:46
in my head connecting. But when I do that, of
9:48
course, I'm making a lot of assumptions. for
9:51
you to actually connect the dots between that
9:54
and a career in surgery. You know, I'm just thinking,
9:56
boy, advocacy, leadership, coming in swinging,
10:01
you know, I'm thinking about all those qualities
10:04
which actually could be put to good use as a
10:08
surgical specialist and as a head of a team,
10:12
often a surgical team. Yeah, so what's funny
10:15
is I came into medicine wanting to do adolescent
10:18
health, thinking that I could. be a physician
10:21
at this kind of crucible moment? Were I able
10:25
to figure out how to deliver a skill set and
10:28
train people to have some internal empowerment?
10:33
In my mind, I call that resilience. That would
10:36
be kind of the perfect setting for me to apply
10:38
that and have a lot of contact with young people
10:41
so that I could reach a lot of folks. And that
10:45
was my intention. I went to the University of
10:47
Minnesota. They have a history there in their
10:50
research arm of really revolutionizing how we
10:55
understand adolescent health. They were actually
10:58
the group that took a huge national, the first
11:02
huge national study of adolescents, and from
11:05
it distilled out the idea of resilience as a
11:07
concept and studied it scientifically and began
11:11
to define both what it is and where it comes
11:13
from. Their work is amazing. Ann Mastin was really
11:18
at the head of that, and she just deserves credit
11:21
and gratitude from so many people, myself included.
11:25
And so I went there to be around that, learn
11:29
from that. And luck would have it, I felt so
11:34
strongly about this that when it came time to
11:37
arrange the other rotations that are required
11:39
of a physician, so you do. one of everything
11:42
whether you are interested in it as a career
11:45
or not and when it came time for me to arrange
11:48
my surgical rotation the word on the street was
11:51
that if we went to this site up in northern Minnesota
11:54
we wouldn't have to do anything we could just
11:57
study and not be a surgeon and that was absolutely
12:02
wrong it was completely backwards to the truth
12:05
it turned out Quite recently, around that period
12:09
of time, they had hired a young woman colorectal
12:12
surgeon who was new there and super busy, super
12:16
hungry, super wonderful. And there were no residents.
12:21
So I became her person. And it was amazing for
12:26
me. I think having that close of a relationship
12:29
to a surgeon over that period of time and quite
12:32
honestly. seeing the first time a belly was opened
12:36
in front of me and like what this magical thing
12:41
is that creates us that we grow from basically
12:44
two seeds into this insanely complicated absolutely
12:49
beautifully running machine i just wanted to
12:53
be around that for the rest of my life and i
12:55
i actually thought long and hard on it worried
12:59
that there would be no place where these two
13:02
things this passion and desire of mine to advocate
13:05
and help individuals with skills i was worried
13:09
that that would never intersect with my chosen
13:12
profession of surgery but that turns out to not
13:16
be true which is a different conversation but
13:18
yeah that's how i landed there yeah i likewise
13:23
had that same sense of just awe completely awestruck
13:27
by the body and the interior this a place where
13:31
most of us don't really get to peer into and
13:34
then to make that a life's work. I totally understand
13:37
the seductive nature of that, but also the challenge.
13:41
And I think it wouldn't be a stretch in my mind
13:44
to think that all those other elements, advocacy,
13:48
working toward some kind of equity in health
13:52
care, could all be part of that, no question
13:55
about it. As we move into that, I actually am
13:58
really curious because I want to know too, It's
14:01
been some time since I did my surgical rotation.
14:03
I didn't go a surgical path, went a medical path.
14:06
But if you could describe for our listeners the
14:08
learning environment and surgical training, how
14:10
you found it, how it is now, and some of the
14:16
groundbreaking work that you've really done on
14:18
how to really look at that environment and glean
14:21
from studying it and exploring it, what are the...
14:26
pain points but not only that what are the most
14:28
likely places of intervening to improve the well
14:31
-being and hence the quality of surgical care
14:35
because i think your work is just amazing but
14:38
yeah first maybe just describe to us that environment
14:42
the other thing Carter that i was just impressed
14:45
with when i read about you is how it sounds like
14:49
you're in an environment which is just absolutely
14:51
wonderfully supportive and people of great humility
14:55
and great skill and great accomplishment all
14:59
together. So it's a really lovely surgical environment.
15:02
Many of us outside of that field don't have that
15:06
impression of the field. And so it's refreshing
15:08
to hear about that. So I spent almost 10 years
15:12
as a biochemist before I applied to medical school,
15:15
before I was accepted to medical school. And
15:18
for the first, I don't know, eight and a half
15:21
or nine of those years, I just had planned to
15:24
be a scientist and thought that if I went back
15:26
for more education, I would get a PhD in biochemistry.
15:31
Biotech is really wonderful because there's no
15:34
glass ceiling when you're in a small company.
15:37
And so not having an advanced degree wasn't a
15:41
hindrance to me taking on a lot of responsibility
15:44
and complexity. But of course, the writing was
15:48
on the wall as the company grew, but that wouldn't
15:51
be the case. And so I, going forward, and so
15:54
I made this decision regarding medicine in light
15:58
of these kids and my feelings about this stuff.
16:01
And I, the timing of me entering medicine coincided
16:07
with really the first application of a protected
16:12
work week in the history of medicine. So Libby
16:17
Zion is a young woman who died. Many people know
16:20
her name. because she died under circumstances
16:22
where her parents, her father in particular,
16:26
who was in the legislature, really used this
16:30
as a moment to talk about exhaustion and being
16:35
overwhelmed within medical professions and medical
16:38
training. And over a course of time, that manifested
16:42
in its first wave as limiting the work week to
16:46
80 hours for medical trainees. While that was
16:52
all initiated, I think 2003 was when that landed.
16:56
And I started medical school in 2004. For the
17:00
first many years, it was a lot on the books,
17:03
but it didn't really occur in real life. So when
17:07
I did my surgical rotation, a lot of it was still
17:10
kind of old boys club, kind of rough and tumble,
17:14
a lot of cursing and like a real team spirit.
17:19
but a lot of kind of jocular behavior. It also
17:23
was very long hours. And yet I have to say, I
17:26
don't really necessarily think that what I was
17:28
exposed to was old boys club behavior because
17:31
I felt perfectly at home. I swear, I have a goofy
17:35
sense of humor. I love hard work. I have always
17:39
loved being on sports teams. I'm really a physical
17:41
person. I don't mind a hierarchy. I don't mind
17:44
following the lead with the... plan that someday
17:49
I will have to lead. None of that bothered me.
17:52
And so that part of it, my medical school exposure
17:56
was actually just reinforcing that I would not
17:59
have a problem in this environment. When I began
18:03
to get an inkling that I would want to be a surgeon
18:06
for life, I actually called my husband driving
18:09
back from this northern remote site to the city
18:12
where we were living. And I said, you know, I
18:15
think I want to do this, but I'm really afraid.
18:19
You know, all we hear about is that people get
18:22
divorced and become jerks and eventually are
18:26
just machines and machine -like towards their
18:30
patients. And I just don't think I could bear
18:32
any of that. And I'm really grateful for him
18:36
because he said this rotation. is where I've
18:42
heard you describe working the hardest. And it's
18:44
also where I've seen you be the happiest. So
18:47
go with that. And then number two, have your
18:50
own experience. Like allow yourself the possibility
18:53
of creating your own experience. If you want
18:56
to be someone who's happily married forever and
18:58
is a surgeon, let's make it that way. We've been
19:01
married 27 years and are super happy. So that
19:04
was how I was thinking about it. I didn't go
19:06
into it blindly, but I also knew my Early experience
19:10
didn't reflect those challenges. When I started
19:13
training, people would say, record your 80 -hour
19:17
work week, right in the eight, right in the zero,
19:20
and then go do your training. And so we worked
19:24
110 hours easily in the first at least couple
19:27
years I was in training. Slowly but surely, the
19:30
regulatory bodies that were meant to... support
19:34
these changes, got smart about it and started
19:36
tracking things like when people badged into
19:38
the hospital and so on. So by the time I graduated
19:42
as a chief resident, we really were working roughly
19:45
80 hours a week, maybe 80 to 90. So it was very
19:50
tiring. It was also just kind of an amazing experience.
19:55
I did on occasion end up in an OR or a work situation
20:01
with someone who was sexist or grotesque. I did
20:04
experience some sexual harassment when I was
20:07
a trainee, which, of course, I just had to suck
20:10
up because certainly then and to some extent
20:13
now, that is not the only person who suffers
20:17
when that gets reported is the person who does
20:19
the reporting. But that was in the minority of
20:21
my experience. Most of my experience was like
20:25
being in combat with people, this unparalleled
20:30
exposure to these incredibly emotion and energy
20:36
-laden experiences that were inarguably impactful
20:41
on others' lives, learning how to fix problems
20:44
with my own hands, finding a place for my indefatigability
20:49
and desire to advocate, where I was applying
20:53
this to patient after patient and just seeing
20:57
how much it helped. It was wonderful. It was
21:00
really wonderful. Now that said, the advice I
21:04
got at the beginning, and this pretty much held
21:06
true to the end, was if you shut up and no one
21:10
knows who you are by the end of your training,
21:12
which is five to seven years long, you've done
21:14
a good job. Other advice I got was no one cares
21:18
what you think until you're four or five years
21:22
into this. So do yourself a favor and just watch
21:26
and learn. People regularly screamed at us. Threw
21:30
shit at us. Really aggressive, kind of horrible
21:34
treatment. Had just massive temper tantrums that
21:36
were just directed on us. But that didn't really
21:39
outweigh the rewards. So what's changed now,
21:46
and this is to some extent, I think maybe the
21:49
pendulum swinging a little bit too far. I think
21:52
residents are respected. That kind of abusive
21:56
behavior is just not tolerated. Perhaps it is
21:59
in some places, but increasingly it is tolerated
22:03
nowhere. There's a sense of appreciation for
22:06
residents, not just a sense that they should
22:08
appreciate what they've been given. There's also,
22:12
of course, a huge discourse about well -being.
22:15
There's a huge move towards increasing more well
22:17
-being resources. And those are all things that
22:20
I've seen since, really since I became faculty
22:23
at UCSF back in 2016. Wow. So could you then
22:29
from that, give us a sense of connecting what
22:33
you've talked about, spoken about, or written
22:36
about the science of surgeon well -being and
22:39
why that would be important then. Why is that
22:43
important for the surgical trainees? Why is it
22:46
important for the field of surgery? And why is
22:48
it important for patients? and for the healthcare
22:51
system. And yeah, just kind of connect those
22:54
with us so we can begin to move into that direction
22:57
of flourish. It wasn't meant to flourish in surgery.
23:00
Yeah. Yeah. Well, there's a lot to that. I guess
23:05
the first thing is, you know, how did I come
23:07
to study this in surgeons? When I was offered
23:10
my first academic surgical job, my chair told
23:13
me, we want you to work here, but this is a huge
23:16
academic center. What is your focus of scholarly
23:19
work going to be? And this was a woman, Nancy
23:23
Asher, who I admired just unendingly, another
23:26
amazing person in my path through life. And so
23:31
I just told her the truth. I told her about the
23:34
kids. I told her about wanting to develop a skill
23:36
set. I had sort of jumped over this, but In those
23:41
years that I was working as a biochemist and
23:43
reading the scientific literature, I came to
23:46
find out about resilient science and Ann Mastin's
23:50
work and what was going on there. I also started
23:52
reading about mindfulness meditation. Those two
23:55
worlds were very, very separate until really
23:58
like the early 2000s. And what happened in the
24:01
early 2000s was that people started publishing
24:04
on changes in neural substrates. that were either
24:08
recognized in folks who were resilient, for instance,
24:11
let's say military veterans, people who survived
24:14
trauma, and were studying the changes in neural
24:18
substrates that were happening in people who
24:20
were either learning to or who were experts at
24:23
meditating. And to my eye, those things were
24:26
the same. The neuroscience at this time was a
24:29
bit rudimentary compared to now, but the idea
24:32
of the same pathways, the same general parts
24:35
of the brain being engaged, was clear to me.
24:38
And so I began to think perhaps mindfulness could
24:42
be a way of training resilience. Perhaps it would
24:46
accomplish the same things in the mind and in
24:49
people's behavior. Turns out that's true. But
24:53
at the time I didn't know that and was moving
24:59
forward with this idea of bringing science to
25:01
bear on this issue of promoting resilience in
25:05
individuals. and potentially using mindfulness
25:07
as the way to go about that. So I proposed all
25:11
of this to her and told her that my real goal
25:14
was to do it in marginalized youth. And she said,
25:18
well, we don't have any marginalized youth here,
25:20
but we have another super stressed population,
25:23
and that's surgeons. And at that point in time,
25:27
burnout was very new on the map. The first article
25:31
about burnout and surgery that really... chronicled
25:35
it, that measured it, came out in 2015. So this
25:40
was just emerging, although burnout as a concept
25:43
in the literature goes back to the early 80s,
25:47
where pediatricians were some of the first group
25:50
to name burnout and claim it as something they
25:54
were experiencing in their primary care settings,
25:58
their ambulatory and primary care settings. So
26:01
I thought, well, At least this gives me some
26:05
surgical, pardon me, some scientific setting
26:08
in which to test my ideas and see what might
26:12
happen. And I love working here. I want to be
26:15
a surgeon here. So, okay, let's do it that way.
26:19
And she gave me various, very generous support
26:22
in the first few years, a lot of encouragement.
26:25
You can imagine at that time, the idea of wellbeing
26:29
was really something only weak. disease needed
26:32
in every walk of medicine. We were still discussing
26:36
if well -being was just a need of people who
26:39
probably shouldn't be in medicine at all. And
26:41
then things like well -being insurgents were
26:43
just completely contrary to each other. And the
26:46
idea of meditation insurgents was for the nice
26:50
people laughable and for the not so nice people,
26:53
just a tirade of what a dumb idea that was. So
26:57
it was wonderful to have some people who believed
26:59
in this, or at least believed in me. I ended
27:01
up designing my first randomized controlled trial
27:03
and in 2016 initiated that with the incoming
27:06
class of first -year trainees and taught them
27:10
only slightly modified form of mindfulness -based
27:14
stress reduction, which is the most codified
27:17
and well -studied form of mindfulness -based
27:19
intervention available at that time. And I purposefully
27:25
planned for really comprehensive assessments.
27:29
So measures of perceived stress, measures of
27:32
perceived burnout, but also physiologic measures
27:36
of change in pro -inflammatory markers, change
27:40
in cortisol levels, like hair cortisol. I did
27:43
functional fMRI. I did surgical skills testing
27:47
because I didn't know where the effects might
27:50
show up if any effects showed up at all. This
27:53
was all pilot work. So where I'm going with this
27:57
is that the... interns, the first year trainees
28:00
who enrolled in the study and were randomized
28:04
would come periodically for these assessments.
28:07
And the first assessment was before any of this
28:10
started. So not just before they got exposed
28:12
to the intervention, but also before they'd had
28:14
even one single day of residency. So I got them
28:18
at their true baseline. Then they came in, they
28:21
got slightly oriented. They underwent the intervention.
28:24
And then I did like a post intervention evaluation
28:26
and then another one a year out. And I saw such
28:32
an unbelievable change. So they would come in,
28:36
you know, at this baseline assessment, they're
28:38
hot shots. They're just out of medical school.
28:40
They've been accepted to UCSF. You know, it's
28:42
like the pie in the sky. And when they go into
28:46
the, you know, fMRI scanner. They usually get
28:49
tucked in with a blanket, you know, because the
28:50
room is cooled to run this great big machine.
28:53
And they have to go into this little tunnel.
28:55
And so it's really kind of like tucking people
28:56
into bed. And even though these are young adults
29:00
in medicine and surgery, you know, interns are
29:03
in many ways thought of as kind of like children.
29:05
And that's not meant to be insulting. It's just
29:08
this weird way that our trajectory and hierarchy
29:11
work. So I would tuck these guys in. And when
29:15
I did it. When they first came to their residency,
29:19
they were all bright -eyed and full of promise
29:21
and telling me about what they were interested
29:22
in. They were with me for a couple hours during
29:25
this assessment day because there were so many
29:27
different things for them to do. And I really
29:29
got to know their personalities. And then I would
29:32
see them two or three months later after they'd
29:35
had the intervention and spent some time being
29:37
interns. And they were exhausted and a little
29:43
bit demoralized. made more comments about what
29:47
they don't know and what they were struggling
29:48
with than what they do know and what they hope
29:50
to accomplish. And it really struck me that they
29:55
are like a precious resource. These people who
29:58
come in with all of this capability and commitment
30:02
towards helping others. And I was watching it
30:06
being ground out of them. And that was even more
30:09
clear at the one -year follow -up. So that was
30:12
how I really came to think that there was an
30:15
importance, even here, in people who you might
30:18
think are the most privileged. And then, of course,
30:21
as I've been learning over the years, changes
30:24
in systems and culture as well. Can you say anything
30:28
about what those changes they were undergoing
30:33
through their training that was happening to
30:35
them emotionally, physically, probably cognitively
30:38
in some way? Why that's important. Do you have
30:41
any evidence or suspect or know that that has
30:46
downstream effects on their ability to do their
30:49
job and to deliver surgical outcomes with high
30:52
quality? Yeah, so I didn't design those early
30:56
randomized controlled trials to follow them out
30:59
for seven years. I'll circle back on that in
31:03
a minute. But what I could observe was an affective
31:07
change. One that involved more self -doubt, which
31:11
in some ways is good, right? You know, you can
31:13
be a superstar fourth -year medical student,
31:16
but that doesn't mean you know anything about
31:18
surgery. And the most dangerous trainees are
31:21
the ones who come in thinking they know it all.
31:23
Those are the ones who don't ask for help, the
31:25
ones who make this great decision in their own
31:28
minds, which actually is dangerous. But it was
31:32
more than that. It was a greater sense of doubt
31:34
about what they were there for. a little more
31:37
demoralization, and definitely an increasing
31:41
sense of kind of frustration, frustration with
31:45
patients, like a little less kindness, a little
31:47
less giving, and a little more angry at others.
31:51
That was also backed up with the data. So over
31:54
the two randomized controlled trials that we
31:56
did in a several -year period, we saw that strictly
32:01
on a physiologic measurement of pro -inflammatory
32:04
gene expression, that residents who experienced
32:09
no intervention from pre to post, they showed
32:14
an upregulation of their pro -inflammatory markers,
32:18
which is equivalent to magnitude of change that
32:22
we see in people who starve or are sleep deprived
32:25
or have experienced physical trauma. In the residents
32:30
who got this intervention, we saw that that was
32:34
decreased. by about 75%. So it doesn't fix people.
32:39
It doesn't make them completely resilient to
32:41
the hardship, but it reduces it. It mitigates
32:44
it substantially. And that's a completely objective
32:46
measure. That doesn't have anything to do with
32:48
anyone's personality or what colors they like
32:52
or anything. That's probably the most convincing
32:55
change. But then we also saw that there were
32:57
benefits, pilot data benefits, so I don't put
33:00
too much stock in this actually, to their...
33:03
executive cognition and to their surgical skills.
33:07
But that's all data that needs to be reproduced
33:11
in a much bigger sample. What we have seen since
33:13
then, for instance, in some longitudinal studies
33:16
with the intervention that eventually came from
33:19
all of this, the mindfulness -based intervention
33:21
we developed, we have seen that in longitudinal
33:23
studies, for instance, in the UK, surgical residents
33:26
who get this intervention as incoming trainees
33:32
Two years later, when it's time for them to be
33:36
accepted into fellowship training, those who
33:39
had the intervention had a 13 -fold greater odds
33:43
of being accepted into top -tier training positions.
33:47
So it affects something in how they interact
33:50
with others, how they move through their career
33:52
pathway, something. And that was under a multivariate
33:55
analysis. You know, that was an independent predictor.
33:58
I was just reflecting as you were speaking, you
34:01
know, we can kind of connect some of those dots
34:03
ourselves. And we had a guest on this podcast
34:06
a while back named Pat Crosscarry. Pat's an emergency
34:11
physician in Nova Scotia, in Halifax. But before
34:15
he did that, he was an experimental psychologist,
34:17
a scientist. And he studies how we think. He's
34:20
a cognitive scientist. And certainly he made
34:23
a very compelling case about... physical, cognitive,
34:28
and emotional factors that impact very directly
34:32
decision making and functioning. So I think those
34:35
measures that you did are, I think, very important
34:38
and maybe surrogates for other outcomes. And
34:42
then I also had read in your work about some
34:46
gender differences and even, say, ethnic differences.
34:51
Can you say anything about some of that that
34:54
you've discovered? There's a few parts to the
34:59
work I do. One is just trying to understand the
35:02
burden of burnout and the burden of stress and
35:05
what does it come from? I focus specifically
35:09
on surgeons, not because I think they're more
35:12
important, but mainly because that's who I know.
35:15
That's the culture I'm most familiar with. I
35:18
feel like those are the people I can advocate
35:19
for with integrity. But also I figure if we can
35:24
learn this about surgeons, then perhaps we can
35:27
take what we learn and then extrapolate as needed
35:31
to other branches of medicine. So we look at
35:34
burnout, trying to understand where it comes
35:36
from, what causes it. Then we look at this intervention.
35:39
It's called ESRT or enhanced stress resilience
35:42
training. And that was really sort of our streamlining
35:45
and simplifying and culturally adapting mindfulness
35:50
-based stress reduction to something that appeals
35:52
to surgeons. It fits within our super complicated
35:56
work and educational lives. And it comes across
36:01
in a way that surgeons can receive it. So then
36:05
the third part is looking at how do the drivers
36:10
of burnout and this intervention act differently
36:16
across different medical specialties, different
36:19
genders, different races, or even just different
36:22
locales. So surgeons at UCSF may have a very
36:25
different experience than surgeons in Kentucky.
36:28
So within all of that, some of our work has been
36:32
pretty rigorous and very promising, enough so
36:35
that we're working on much larger federally funded
36:39
trials. And that's really around the intervention.
36:42
There's just a lot to say that it's effective,
36:45
but now we just need to show that in a bigger
36:47
group. Some of the burnout work we've been able
36:50
to look at in larger groups. Because obviously
36:53
you can study burnout using the kind of gold
36:57
standard instrument today, which is the mass
37:00
-like burnout inventory. You can study that with
37:03
just like a survey. And so we've done some work
37:05
around sending out the burnout inventory with
37:09
other measures to hundreds of surgical trainees.
37:15
And there are some groups that have even sent
37:18
this out to thousands of surgical trainees. That
37:22
work, which I think is probably the most definitive
37:24
because it captures almost the entire population
37:27
of general surgery trainees, but reflects the
37:32
same things our smaller work found, which is
37:35
that absolutely there are differences in how
37:37
burnout is experienced in non -males and people
37:42
underrepresented racially and ethnically in medicine.
37:47
There are different drivers for both of those
37:49
things. Some are the same, being overworked drives
37:52
burnout and depression in all groups. So some
37:57
of this is based on what we know are just different
37:59
lived experiences. And so, for instance, harassment
38:03
and bullying and sexual harassment, being excluded,
38:07
not belonging, not being encouraged to feel that
38:10
they belong, are particularly potent factors
38:14
that influence. burnout and stress in non -majority
38:19
groups. That's fascinating and I think it also
38:23
tells us that the future of intervention development
38:27
has a lot to do with the precision to which we
38:30
can tailor those interventions appropriately
38:33
and you're talking about that and even discuss
38:37
in some of your work how you use try to discover
38:42
workplace factors to target in the design of
38:45
intervention. So I really like the scientific
38:47
approach. And I think having your background
38:50
and as a scientist in training before you became
38:54
a surgeon is really, really helpful. And having
38:56
a environment at UC San Francisco in your division
39:01
and department that really wants you to approach
39:04
whatever problem you want to approach in this
39:06
way, I think it's very powerful. So your work
39:08
will have a lot of ramifications. Maybe you can
39:11
tell us about, you mentioned about larger trials
39:15
of this ESRT intervention. Other ideas that you're
39:18
contemplating for the work in your lab for the
39:21
program of surgical resilience, surgeon resilience
39:23
in general? One thing our group does is share
39:28
ESRT to those who want it. And it's not a profit
39:32
-driven endeavor at all. So it's very much, it
39:34
costs only what it costs to run it, to have a
39:38
teacher. That program. we're finding accomplishes
39:42
a couple of things. It helps people reclaim some
39:46
of their joy in the work that they do. It helps
39:50
people capture a few, like in a more deep way,
39:54
some of the moments of satisfaction that are
39:57
still available in their work or more importantly,
39:59
available outside of work and experience those
40:03
things a little more fully, even in the midst
40:05
of this system that is increasingly strained.
40:08
But one thing we've been noticing in the last
40:10
few years to this wide variety of groups that
40:13
we've been sharing this intervention with, which
40:16
includes ICU nurses, internal medicine specialists,
40:20
emergency medicine, trainees across different
40:23
programs, surgeons in different countries. And
40:26
what we find is that it also tends to bring people
40:30
down off the ledge, if you will, from their demoralization
40:34
and rage about this burnout problem. And our
40:39
shared understanding, not just among health care
40:42
providers, but really anyone who studies this
40:44
at all or experiences it, is that it's a problem
40:48
rooted in systems that aren't working for us
40:51
and a culture that apparently doesn't care because
40:55
we've been studying burnout now for 10 or 15
40:58
years and 15 or more years and really touting
41:02
the clear relationship between burnout and depression
41:05
or burnout and suicidality. Burnout and decreased
41:09
quality of care, perhaps not danger to patients,
41:12
but really rather less of that human connection.
41:16
So still safe, still good, but certainly not
41:19
as connected and humane as we would want. And
41:23
those sequelae of burnout just haven't really
41:27
changed the systems we work in or the people
41:31
who can control those systems much at all. What
41:36
we're finding is that one way that ESRT is of
41:40
benefit is that it helps people remember that
41:44
they have a better idea of what's wrong than
41:46
anybody else. And so whether you're in Kentucky
41:51
or in California, whether you're a surgeon or
41:54
a gastroenterologist, you can name, better than
41:58
anybody else can outside of your group, what's
42:01
wrong and what needs to be fixed. in my mind
42:05
and supported by occupational science which has
42:08
been around for decades and decades looking at
42:11
other professions this is the clearest and most
42:14
precise way to get at what needs to change in
42:17
an individualized way you know individualized
42:19
to that site individualized to that specialty
42:22
so number one it's it's asking people can you
42:26
ground your mind can you clear your mind from
42:28
very well -deserved anger and focus on what's
42:33
the one thing that you still like about your
42:35
job? How can we protect that? How can we promote
42:39
that? How can we stop whatever's eroding it?
42:41
And then what's the thing that's just killing
42:43
your joy? Okay, how can we change that? How can
42:47
we make a true incremental effect on that thing?
42:50
And so a lot of our research focuses on that.
42:52
We use scales, measures that have sort of big
42:57
bucket domains that we can get statistically
43:00
relevant data from. For instance, demand workplace,
43:04
demand control and support. Those are big topics.
43:07
We can show that, for instance, control plays
43:11
a really big role in, say, surgeons, and we need
43:14
to address it. But then we use qualitative methodology
43:16
to ask surgeons at different sites, at different
43:20
levels of their career, what does that mean to
43:22
you? Because we can't do anything in terms of
43:25
designing an intervention unless we understand
43:27
what exactly does control mean. A larger question
43:31
is, let's say that we figure out that control
43:34
means a certain thing to surgeons in this region
43:37
of the United States. And there's a clear thing
43:40
that we can try and change through a real systems
43:44
renovation in this area. So something doable,
43:48
you know, nameable, operationalizable, doable.
43:51
How do we get the people who are in charge to
43:55
actually do it? And so that's where We've started
43:59
working more closely with the American College
44:01
of Surgeons, which particularly under their new
44:04
executive directorship with Patricia Turner,
44:07
has become a very strong organization of advocacy,
44:12
not just around Medicare payments or something
44:15
along those lines, but really around kind of
44:18
the life and the experience that surgeons have.
44:21
There are professional organizations for every
44:24
kind of medicine that parallel this. Working
44:27
with the American College of Surgeons, we've
44:30
designed over the last, it's taken a couple of
44:33
years to do it, a survey that will be launched
44:36
to about 75 or 80 % of all actively licensed
44:42
and working surgeons in the United States, about
44:45
80 ,000 people, to describe their workplace processes.
44:49
And it's complicated, but what we're trying to
44:53
get at is, what is it about the workplace? wherever,
44:57
whatever region of the United States you're in,
44:59
whatever particular institution you work for,
45:02
that correlates with ill or well -being outcomes.
45:08
And then taking the broader data context, which
45:14
has been developed by many others over years,
45:17
showing that ill -being or well -being we know
45:21
is directly correlated to outcomes, you know,
45:25
attrition. patient outcomes, litigation, and
45:29
so on, we can then make an argument that these
45:33
workplace processes drive burnout in the Northeast
45:36
and they specifically need to be changed. And
45:40
we know they're directly linked to, associated
45:43
to these poor outcomes in terms of performance
45:47
for a healthcare institution. And if you don't
45:52
make these changes, like consider this a metric
45:54
of your evaluation of your progress on an annual
45:58
basis and make inroads into changing it, we won't
46:02
certify you as a center of excellence. We will
46:04
lobby nationally so that regional and national
46:07
governing bodies don't give you trauma accreditation.
46:10
If necessary, we'll create a U .S. News and World
46:13
Report, 10 Happiest Hospitals, and we'll rank
46:17
how your surgeons are doing. And our hope is
46:20
that Other medical specialties will do this too.
46:23
And that's not meant to become adversarial. That's
46:25
not meant to point fingers at others. But it
46:28
is meant to say there are changes happening in
46:30
medicine. And this burnout phenomenon is not
46:33
an individual issue. It is a much bigger issue.
46:37
And going back to the very beginning of this
46:39
conversation, if we lose human beings who are
46:44
willing to sacrifice a tremendous amount of years,
46:48
personal life, personal gain, as well as just
46:53
physical well -being on a day -to -day basis,
46:55
not eating, not peeing, not sleeping, in order
46:59
to take care of strangers, in order to be drawn
47:02
to a vocation that requires them to sacrifice
47:06
their own well -being at times to take care of
47:09
strangers. If we lose that, which is what medicine
47:13
currently represents in our civilization, we're
47:16
losing a pillar of civilization. So it's not
47:20
a small issue. It's not about doctors wanting
47:22
to be paid more. It's not about people wanting
47:25
to pass the buck and point the finger when we're
47:27
all in a difficult situation together. We're
47:30
talking about really fighting for something that
47:32
is irreplaceable if we lose it. And that's individuals
47:37
who are willing to go into this work. I agree
47:40
with you 100%. In fact, what draws me to this
47:44
work, as you know, is... that same idea that
47:47
this is a precious precious precious human resource
47:50
that as a social species we absolutely rely upon
47:54
and that we really want to protect that resource
47:58
and enhance that resource i want to name four
48:02
things that you mentioned which i think are really
48:04
really important as we begin to come to a close
48:06
one is resilience our medical professionals surgical
48:11
professionals across the board as a whole, as
48:15
you've mentioned, are already highly, highly,
48:18
highly resilient. And then what they're facing
48:21
is truly the crisis of systemic issues that are
48:26
really driving that burnout. So that's the first
48:28
thing. And I think acknowledging that up front,
48:31
especially in interventions that you're doing
48:34
that we're doing that seem to be so individually
48:37
focused we can sometimes appropriately be asked
48:41
questions about that the second is the precision
48:44
which which you're trying to develop the right
48:47
kind of interventions in the right places address
48:49
addressing the right problems that are one size
48:52
fits all isn't going to work but that we have
48:56
a science around this that can do that and you've
48:59
named that and spoke about that so beautifully
49:02
I like also that you brought in when you are
49:05
working on an individual levels, helping people
49:08
be able to frame their experiences to include
49:11
at least somewhat an appreciation for those things
49:15
that are actually already working for those capacities
49:18
and qualities that they already have. I think
49:21
it's really helpful when one is stuck in a milieu
49:25
of disaster and problems to at least be able
49:30
to see something that's good there and then finally
49:33
you sort of open this last piece with joy and
49:37
so I wanted to give you a chance as we kind of
49:39
come to a close Carter to talk a little bit about
49:42
like the joy that you get out of this but also
49:45
what other things do you do in your life because
49:47
you're so very interesting and all the things
49:49
you've done that bring you joy that really are
49:52
part co -extensive with you know, your medical
49:56
work that are part of you that aren't really
49:59
separate from who you are? Maybe you could share
50:01
that with our listeners. Yeah, well, I get a
50:05
lot of joy really from being outdoors. I get
50:10
a lot of peace from being in the outdoors. San
50:13
Francisco is a beautiful city for that. We just
50:16
have so much green nature right amongst us or
50:20
nearby. I get a lot of joy from being around
50:24
people who aren't physicians. Not that we aren't
50:30
great, but just being around normal people, you
50:33
know, with normal lives who are just enjoying
50:36
sitting in the park, taking a walk, petting a
50:40
dog, really simple things actually. And I enjoy
50:45
going running. That kind of brings a lot of it
50:47
together. You know, it's very, very simple and
50:49
it's outdoors. I find, though, that those aren't
50:53
big, complicated, sexy things, but it's really
50:57
just making time for them and being present in
51:01
them that just makes them rejuvenating for me.
51:05
My husband is a normal person, so that spending
51:09
time with him gives me that taste of just being
51:13
a person again, but also strengthens my relationship
51:18
with him. I think those things are... really
51:21
important. Sometimes I think that's one of the
51:23
biggest magic tricks of something like meditation
51:26
is that it can just remind us how much richness
51:30
and beauty there is in normal life, not big,
51:35
effortful interventions or changes, but just
51:39
normal life. Thank you. No, I think you and I
51:43
have a lot in common in that way. When my dad,
51:46
who's been gone for quite a while, toward the
51:48
end of his life, we had a series of conversations.
51:50
And I guess the way I would summarize the conversations
51:53
was the theme was the beauty of the non -superlative
51:57
in our lives. And I really understand. I think
52:00
that's what you're talking about. It's the everyday
52:03
things that actually really matter because we're
52:05
living every day, just in every day, in an everyday
52:09
life, just like every other human being. And
52:12
hence, we can also... have empathy and compassion
52:15
and feel connected to the other human beings
52:18
as well. So you've said it so beautifully. Thank
52:21
you so much. Anything else you'd like to say
52:25
to listeners? Thank you for Mick in particular
52:28
for being part of this and doing this work and
52:31
carrying the torch, paving the way for so many
52:35
of us. I'm grateful to you. Well, the feeling
52:38
is mutual, Carter. Thanks for listening today.
52:41
We will include a summary, of the podcast and
52:44
links about Dr. Lebares and other references
52:47
that were discussed in the show notes. I would
52:50
like to continue to conclude by sharing another
52:54
practical exercise to help you flourish. Today's
52:58
practice can be done really anywhere. And it
53:01
comes out of this discussion I just had with
53:04
Dr. Lebares about the simple things in life that
53:07
provide joy and meaning, but also a recognition
53:09
that our lives are made up of an infinite number,
53:13
of moments, most of them both mundane and simple,
53:17
but also singular and beautiful. So the invitation
53:21
is once or twice a week to remind yourself, wherever
53:25
you are, whatever you're doing, of the following.
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I am alive right now. This is it. Nothing has
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to be different or change in any way in this
53:38
moment. It's simply like this. And here I am.
53:44
Invite yourself to have this reflection while
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walking from one place to another, when in a
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meeting, when at the dinner table with family,
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when in the workplace setting or seeing a patient
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or performing a procedure, whether you're inside
53:58
or outside. Perhaps even typing and pricking
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these words and placing them in a few locations
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as a reminder to yourself. I am alive right now.
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This is it. Nothing has to be different or change
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in any way in this moment. It is simply like
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this. And I am here. I hope you found this podcast
54:24
and this simple exercise useful and look forward
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to having you join us back for the next episode
54:30
of Flourishing in Medicine, From Surviving to
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Thriving. I'd like to thank Jerry Donahue, the
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Vice President of Education at EmPRO and Stan.
54:40
Sainjour, our technical director for their
54:43
work on producing this podcast. To learn more
54:46
about EmPRO and their peer support programs, please
54:50
visit www.myEmPRO.com forward slash peer dash
54:54
support. If you're a physician or a medical student
54:58
and you need urgent support, consider calling
55:01
the physician support line at 1 -888 -409 -0141
55:07
or visit the website, www.physiciansupportline.com.
55:13
For more information about me and my work,
55:17
please visit www .MickKrasnermd .com or www.mindfulpracticeinmedicine.com
55:26
Until next time, see you.