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Flourishing in Medicine: From Surviving to Thriving Episode 8 Aviad Haramati, PhD · Flourishing in Medicine: From Surviving to Thriving

• 0:00
  Welcome to Flourishing in Medicine from Surviving to Thriving. I'm your host, Dr. Mick Krasner,
• 0:28
  and this podcast is brought to you by EmPRO, a medical professional liability insurance carrier
• 0:33
  headquartered in New York State who's deeply committed to supporting physicians' well-being.
• 0:38
  Their extensive peer support offerings include this podcast. Today, I'm happy to share with you
• 0:44
  my conversation with Dr. Aviad, who goes by Adi Haramati. Adi is a professor of integrated
• 0:51
  physiology and co-director of the graduate program in Integrative Medicine and Health
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  Sciences at Georgetown University Medical Center, coming to Georgetown 38 years ago after five years
• 1:02
  at the Mayo Clinic. In 2013, he was named a founding director of the Center for Innovation
• 1:07
  and Leadership in Education, CENTIL, at Georgetown University. His research interests over the past
• 1:16
  25 years have addressed renal and electrolyte homeostasis, but in the past two decades,
• 1:21
  he's focused much of his efforts on medical education and rethinking how professionals
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  are trained. His teaching acumen and his recognition of that teaching has included
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  11 Golden Apple Awards from medical and graduate students at Georgetown. In addition, he was
• 1:37
  awarded the Arthur C. Guyton Teacher of the Year Award by the American Physiological Society,
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  the Alpha Omega Alpha Robert J. Glazer Distinguished Teaching Award from the
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  Association of American Medical Colleges, the Master Scholar Award from the International
• 1:51
  Association of Medical Science Educators, and he's been named a Distinguished Educator by the
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  Georgetown University Medical Center Teaching Academy for Health Sciences. Dr. Haramati has
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  advocated that mindful practices together with small group learning be integrated into the
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  training of health professionals to foster resilience and improve well-being in the learning
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  and work environments at academic medical centers. His educational activities have included visiting
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  professorships at over 100 medical schools worldwide. And in this podcast, he shares his
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  unique journey from studying physiology to becoming a leader in mind-body medicine education. A pivotal
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  moment occurred during a meeting at Harvard Medical School where he realized the importance
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  of medical education professional training, leading him to integrate mind-body medicine
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  into the Georgetown curriculum. He further discusses the transformation of medical education
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  and the evolving understanding of the importance of self-care for medical professionals. Recently,
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  he has introduced a new course called the Course on Human Flourishing, which aims to provide
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  strategies for thriving in medical school and in life. Sharing personal experiences as an educator,
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  Dr. Haramati highlights the joy he derives from helping students discover their potential and the
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  satisfaction of making a positive impact on medical education. And now, our conversation with Dr. Adi
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  Haramati. The first thing I'd like to hear about is why the health professions. So, you know, in my
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  work with students, other colleagues, clinicians, teachers, academics, I've been really impressed
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  by their unique origin story, we can call it, kind of what brought them into the health
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  professions. A lot of times, these are early formative experiences. Sometimes they're experiences
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  they have along their educational pathway continuum. And for some of them, there was no plan,
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  but the path just unfolded for them in that way. So I'd just like to hear a little bit about your
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  own story of how you got here in as a health professional educator. Thanks for the question.
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  It's always interesting. We talk about our work, but rarely do we get a chance to talk about how
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  we got to our work. So let me preface by saying that I'm not a physician. I took a scientific
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  route to what I'm doing today, and pursued a PhD in physiology. And what motivated me to study
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  physiology as opposed to studying medicine, really two things. One is, I actually don't like
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  hospitals very much. And found that just walking into a hospital did not create a good feeling in
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  me. For some people, that's a draw. This is where they need to be. Not for me. But I was always
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  intrigued by the science that underpins medicine, which is why, how does the body functions and why
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  things go wrong. And so physiology to me was the study of medicine. And so in a strange way, I
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  pursued a field that I actually didn't want to deal on the care side, but more on the science and
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  the research side. And throughout my life, I really looked for mentors. I pursued my PhD.
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  Well, first of all, I went to the University of Cincinnati from New York City, because I was
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  looking to leave the noise of New York and see if I could settle into a place smaller, and would
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  give me the opportunity to grow within that more finite context. So I went to a department that was
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  fairly young in terms of age. I think most of the folks were in their late 30s and early 40s, except
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  for the department chair. And then I selected a mentor based on who I thought I would learn the
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  most from. And that actually carried me to my postdoc, where again, I selected a mentor, and to
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  my first faculty position, which was here at Georgetown, again, looking for a department chair
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  that I felt I could learn from, not just who was going to give me the best package. So you could say
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  that this was an early connection with science, but also with relationships with people.
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  And maybe it can help me. You've done a lot of work in mind-body medicine education. Help us,
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  the listeners and myself, connect the dots between renal physiology and what's called mind-body
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  medicine from your perspective and how that unfolded in your experience. So I also really
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  appreciate this question, because the term urine and the term mindfulness are rarely in the same
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  sentence. And so this is part of my trajectory. So I do have to fill in some gaps. I came to
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  Georgetown in 1985. That was 38 years ago from today. And I came really focused on building a
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  research lab, generating data, doing science, training graduate students. That was my focus.
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  And for seven years, that's what I did. Now, when I got there, I was asked, could I teach the renal
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  section of the physiology course? Sure. No problem. The next year, you did such a good job on the renal
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  lectures. How would you like to run the whole physiology course? Well, that was a little more
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  bigger commitment, but I agreed to do that. And for me, the price to do research was I did
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  some teaching. It turned out to be about half a year's worth of teaching, but it's not every day.
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  I mean, it's not every hour. It was every day for a few hours between January and May. And then along
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  the way, I guess I was effective of the students responded well to what I was presenting. I did
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  win a few teaching awards, but for me, during that first seven years, teaching was the price I paid
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  to do research. And then in 1992, so seven years later, by then I had been promoted. I had
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  established myself here at the school. I got a call from the dean one day, which was an unusual
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  thing. It didn't happen every day, but the dean called me and said that they're sending me to
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  Boston for a week. And I go, why? And they said, well, Harvard University School of Medicine
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  has now been four years into their new curriculum. This was 1992. Their curriculum started in 88,
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  their new pathway. And they're inviting every school to send one person to learn about what
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  they've done and to gain some insights, not to necessarily replicate it, but really to participate
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  in some discussions about their curriculum. And I begged him not to send me because I had no
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  interest to go to this meeting. And he would hear nothing of it and basically said, you're going,
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  and then you'll come back, tell us what you learned. So I flew up to Boston, very annoyed
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  that I was going to spend the week listening to how wonderful Harvard was and really engaging in
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  something that I had no interest in. Well, in the first, we walk into this auditorium in building
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  E at the time on the quadrangle of the Harvard Medical School. And two individuals came on the
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  stage. One was Daniel Tosteson, the dean of the school, and the other was Dan Fetterman, the dean
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  of medical education. And as they began to introduce what they were doing and why they felt
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  compelled to host this meeting, I felt my entire view of my job completely change. And I was
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  mesmerized. And the basic message that Tosteson provided, who was a physiologist by training,
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  was this. You are working in a medical school and your primary job is to train a health professional.
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  Yes, we are hired to do research. Yes, we're hired to see patients. But the reality is you're
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  training a professional. And yet we don't take our education as seriously as we take our other
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  endeavors. And that is wrong. We wouldn't think of walking into the operating room without a
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  carefully delineated protocol. We wouldn't think of walking into the research lab without a
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  carefully delineated protocol. How is it that we could walk into a lecture hall and not really
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  have a good sense of what we're doing? And frankly, teaching at that time was coming into a room,
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  telling people what you know, exchanging content or transmitting content, and then a few weeks later,
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  finding out what the students remembered from what you delivered. That's not education. But I was
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  hooked. And then another serendipitous event at that particular meeting was that we were assigned
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  to groups to learn about problem-based learning, which is a teaching pedagogy. It's a methodology
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  in which cases are presented and students learn to work through cases. And I was assigned to a
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  group that was led by what? A nephrologist, who I happened to know by reputation I've ever met. And
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  the case was a case of a child in Africa with a refugee child with Kwashiorkor. That was a
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  fluids case. I was mesmerized. And I spent a week in the library researching the case and then
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  deciding or planning how we were going to change the curriculum so that I could actually implement
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  some of this. And I came back to Georgetown after we completely energized by the fact that I am now
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  going to spend 50% of my time on education. So that was the first phase. And that went from 92
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  to 97, where my focus was, how do I use science to train a professional? How do we use science,
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  for example, to shape attitudes? And we have a tendency in the sciences to read through a case
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  and immediately go to the data, the numbers. What are the lab values? Let's make a diagnosis and a
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  treatment plan. And I didn't do that. I actually spent time on the psychosocial descriptions that
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  most scientists skip over because they're not important. But actually for me, that was the
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  whole point of the case, is that the context matters. The social situation matters. And so
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  as I began to think more and more about attitudinal shifts in students and how we could use science for
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  that, the logical question came, how do we train students to meet the needs of the public?
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  And when it came to complementary approaches to care, particularly with chronic illnesses
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  like cancer and arthritis and heart disease, Western medicine is excellent at acute interventions,
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  but is lacking in dealing with quality of life issues. And so things like mind-body medicine
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  to manage stress, rather than taking anti-psychotics or antidepressants that have variable efficacy,
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  or using manipulation instead of surgery, or using massage, or using acupuncture for pain
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  instead of opiates. And so the idea was, well, how are we going to teach students about these
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  aspects? And so I had an opportunity to write a grant to NIH to create a curriculum in our medical
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  school. And I latched onto it because I thought this is actually a way to teach attitudes
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  and to really prepare students to meet the needs of the public. And so we wrote a grant to NIH to
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  create an integrated medicine curriculum that was not a $50,000 grant. It was $1.6 million over
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  five years. Yes, exactly. This is significant dollars for a curriculum grant. And what do we
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  do with the money? What we did is we bought people's time to actually invest in making
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  something that would be long lasting. Part of this was to decide what students should know.
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  And then the other component was what experiential elements could actually be used for the betterment
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  of the student life. And that is how I brought mind-body medicine. I went to get trained myself
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  with other clinicians, even though I'm not a clinician. They were looking, how do we use my
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  body in our practice for patients with chronic pain, with cancer, with heart disease, as support
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  groups, as tools for self-care? And my approach was how do I create an educational intervention
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  that will immediately impact on our students because it will give them tools to help themselves
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  as a start. And when they learn to help themselves, then they can learn to help others.
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  So that was a long-winded answer, how I went from renal physiology to mind-body medicine. Now I still
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  to this day direct the renal module, but I also to this day co-lead the mind-body medicine program.
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  You know, it's so fascinating, this story of first somewhat being infected, you could say,
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  by the bug of medical education, this threshold moment at Harvard Medical School, but not really
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  knowing because you knew science, not really knowing how it would lead to shifts. The next you
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  described is this contextualization in humanism, and then the final shift or the most more recent
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  shift is then self-care, well-being. What does that have to do with professional education? So I knew
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  I was really interested in interviewing you because of your interesting commitment to medical
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  education. Could you maybe share any more observations about that aspect, bringing that
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  self-care or that well-being aspect that has been part of you, we could say your raison d'etre,
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  your reason for being in the game of medical education. You're a great storyteller,
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  so I'd love to hear how you share that narrative with us. So I have more to say about the
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  transition points between self-care and science and the training of a professional. Part of it
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  has to do also with a realization that sometimes you're sitting in a position that's a pivotal one,
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  and you have a choice point to make. You either step into a role that might make you uncomfortable
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  or you could take the safe road and say, let's leave it to someone else. So when I first was
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  thinking about how my body medicine might come to our school, what I was thinking is, let me see
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  what this is, and then let me find the right people that can do that. And I brought a colleague
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  who is a clinical social worker that happened to work with James Gordon to create the training
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  program for the clinician. And so she's an expert in really developing a faculty development program
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  in my body. And I created a pilot in which we would pilot this with our students to see, first of all,
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  how is it accepted and how would we deliver it and just go through the, you know, at least an
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  experimental phase of how this might work. But I made sure to partner with her because I wanted to
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  see her in action. And what impressed me was the way the students responded to these experiential
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  sessions that we had. Because for the students, what this meant was I've spent six months in
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  medical school learning an awful lot about science and biochemistry and the DNA, but where's the
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  patient's part? And then when we started talking about things that affect our lives and tools that
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  could help us, that they reacted to, and they also reacted to the fact that they could hear from each
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  other. And so I began to get fascinated with how the students reacted to it, how my colleague was
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  leading these groups that we were co-facilitating, but she was doing more the facilitating, I was
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  doing more of the observing. And then it came to the point where now I think we need to roll this
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  out. And so the first question I got from folks is why are you involved in this? You're not a mental
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  health professional, you're not a psychologist. And I said exactly. But what we need is we need
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  people that the students see in leadership roles, course directors, clerkship directors,
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  our associate deans. Those are the individuals that need to walk the walk. And what that means is
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  that I ever think that I would lead a meditation group and ring a set of tinsha bells and bring
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  everyone to an intentional moment and then lead a script that John Kabat-Zinn developed
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  for a mindfulness meditation? No, I never thought I would do that. I thought it would be very
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  uncomfortable. In fact, the first time that I did that, I thought I was going to lose my mind because
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  what am I doing? I'm not. This is not my field. But my discomfort was not observed by the students.
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  The students saw, wait a minute, our physiology course director is meeting with us at 630 at night
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  to lead a meditation. What is this? And then you realize that if you're going to make change,
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  you have to get out of your comfort zone and you have to lead and step into the role that you have.
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  And so the reality is, as you probably know, Mick, that there aren't many basic scientists that were
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  involved in this movement. Yes, there were neuroscientists that were doing the science, but the
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  actual delivery of these practices was not. And I thought this is how we turn the wagon. This is how
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  we change the perception. And so I lead with physiology. When I first give a talk on mind-body,
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  I will discuss the brain. I will discuss the cardiovascular system. I will discuss the endocrine
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  system. I'll discuss all the systems that actually can be controlled by our thoughts in ways that we
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  never appreciated years ago. And that once you understand the physiology, if you understand the
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  physiology of stress, you will understand the physiology of distress. And so it turned out that
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  this was exactly the role that I needed to play. And I was not afraid to face critics because
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  when I was challenged, the mind-body component was easy. It's when they challenged me on
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  herbs that I say, you know, you're right. I'm cautious about what I put in my mouth.
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  But if you're worrying about meditation, let me explain to you why physiologically this is actually
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  the best way that we can begin to deal with things. So it was a natural progression, but we also
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  approached this strategically. This is another thing to think about, which is we didn't just take
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  the folks that were dying to do this, in other words, the choir, but rather I was looking for
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  people that were very prominent at our school, but were open-minded. And I wanted the reaction to be,
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  what? You're involved in the mind-body group? Because that begins to change culture.
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  And so that's how we went about it. It's now our 22nd year that we're running these courses.
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  We're expanding them into various sorts, but the impact it's had on our culture at the
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  medical school can't be underestimated. It's something the school is extremely proud of.
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  What I really enjoy about hearing this story is that you're describing in a certain way
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  how you're creating a situation in which the hidden curriculum and the informal curriculum
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  comports with the actual formal curriculum, the vision and mission of medical education.
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  And that's really hard to do. I'm interested, were you surprised by some of the folks who actually
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  came on board as you began to try to recruit those who were not necessarily part of the choir,
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  as you described? Well, I think you know me. You know that no is not one of the words in my
• 20:38
  vocabulary, so I don't let go easy. But for many, it all depends on the approach. I think that I
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  personally was shocked at my own evolution because I was, you know, if you say to me,
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  look, you know, I was born in Israel. I grew up in New York City. I like to say we do judgment for
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  breakfast. And when you think about that, the whole essence of many of these practices is
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  approaching things complete non-judgmental. Set that aside. And I tell people for me to become
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  non-judgmental required almost a DNA recalculation. And yet you can learn to do that. You can learn
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  to listen to the end and not try to finish people's sentences because you're so sure you know
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  what they're going to say. You might be surprised. And so I think my own transition here was
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  perhaps a catalyst for other folks to put their toes in and say, well, wait a minute,
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  you know, he's still teaching renal and he's doing this. What's that about? The other thing
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  I will tell you is that data carries the day. And so we started collecting data very quickly
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  from the first group that we did on a variety of parameters, not just quantitative measures of
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  stress and a number of other things, but empathy, for example, but open-ended questions like,
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  what did this course mean to you? And when students write things like, you know, listening to
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  other students talk about the challenges they face, made me realize I'm not alone. Or the lessons
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  that, you know, I struggle with trying to balance how much time to study and how much time for
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  myself. And I feel guilty when I go take a 30-minute run. And so now I realize that's
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  actually better for me to do. You know, we need to give our students and our colleagues who are
• 22:27
  actually even worship permission to take care of themselves. I mean, your own studies at Rochester
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  have shown that we're our worst enemies, that we know what we need to do for ourselves. And yet,
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  you know, we have a barrier because of the way we're composed and our dedication to others,
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  but that doesn't help people. And that came out in the COVID pandemic. All of a sudden,
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  the school's leadership is asking me to lead a meditation for 500 people on a zoom,
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  on a zoom call. Now, first of all, 500 people coming to a faculty meeting is unheard of because
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  usually 20 show up. But all of a sudden during the pandemic, as everybody's worried about what,
• 23:07
  you know, what are we doing? What are we dealing with? How are we going to teach? How are we going
• 23:11
  to research? How do we treat patients? And then I'm asked to talk about the importance of self-care
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  and why self-care is not narcissism, but actually vital to make you present and available to your
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  family and to your patients and to your colleagues. This was a validation of everything that we were
• 23:28
  doing. And so it's, it takes courage. This is my bottom line. I say that to everybody. I say that
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  to every Dean I meet. You want to change the culture in your school? It starts with courage
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  of you stepping into the. And courage is, you know, in some ways being open hearted in a certain way,
• 23:49
  in a vulnerable way, I guess we could say. I just want to step back. You talked about this colleague,
• 23:57
  this woman who had developed some skills teaching and what was it about her skills and what you saw
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  that you could see in yourself, not only seeing yourself as cultivating as a teacher, but also
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  that you could see in other folks, others of your colleagues cultivating similar skills, that they
• 24:20
  could do this in their own way, with their own signature, with their own personality, of course.
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  So with the risk of embarrassing my colleague, her name is Nancy Harris Duck, and she's a woman
• 24:29
  of extraordinary talent that can bring together a group in a session and she exudes pure love.
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  This is the way she's composed. Everything about her is authentic, and when she leads a group,
• 24:44
  you're just drawn in. And so what I was watching very carefully is how does she do that?
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  What are the words that she say? I'm not Nancy Harris Duck, but I learned a lot from how she
• 24:55
  presents what she's trying to evoke. And then I kind of do it a little bit differently. This is
• 25:02
  why we were a very good partnership, because she came with the pure sense of all I want to do is
• 25:07
  teach this to as many people as I can. And I said to her, we can't get anywhere without data.
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  We're going to have to get data because we're going to need to convince the powers that be,
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  and other medical schools, and the licensing boards, that what we're doing is not just feel good
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  and effective, but it's important that it has an impact and is a way that we need to go. So it was
• 25:33
  a good combination. But I learned a lot from, for example, how she phrased words, how she introduced
• 25:41
  meditation. I can be very technical. She had a much more circumspect view of things. So I encourage
• 25:49
  folks to surround yourself. You hear this a lot. Surround yourself with people that are different
• 25:53
  from you, because together you'll find a path that neither one of you could have done by yourself.
• 25:59
  I think that's right. So from the medical school classroom to the culture of medicine on the wards,
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  to the rarefied environment of organized medicine, organized medical education that you've been
• 26:12
  involved with, for example, the AAMC, the American Association of Medical Colleges. I'd just like to
• 26:17
  hear from you. I'm always curious myself, what do these all have in common? Can you share about the
• 26:24
  commonalities of all these levels of what we could call the culture of medicine? How's it been in the
• 26:30
  past? What it was like? How is it now? And how do you see it evolving with some of our understandings
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  and especially our understanding that well-being of the health professional is actually a quality
• 26:43
  metric? It's a metric that reflects our mission in medicine and what we're here to do.
• 26:48
  You ask an important question, which is medicine is hierarchical. I would say that if we go back
• 26:54
  20, 30, 40 years, the notion of what it meant to be a physician and the degree of service to others
• 26:59
  was paramount. And as the data began to emerge in the last 20 years on burnout, on stress, on the
• 27:08
  impact on caregivers, it became clear to the overriding bodies. The AAMC, for example, the
• 27:15
  Association of American Medical Colleges overseas, all our medical schools, 157 in the United States,
• 27:21
  17 in Canada, 400 teaching hospitals, a whole number of health systems. Looking at the workforce
• 27:27
  and looking at the impact on learners and our faculty prompted the AAMC to begin to start taking
• 27:36
  stress and burnout very seriously. Part of it has to do with the way the system operates in its
• 27:43
  academic pursuits, the delivery of care, the pressures on research, the challenges in teaching
• 27:50
  as teaching has evolved. And we're moving away from the lecture hall and more into simulation labs
• 27:56
  and into small group activities. And even teaching on the wards has changed. There was a realization,
• 28:03
  a very important one, that we're human, that we have frailties, that we have limits, and that
• 28:09
  perhaps holding off on self-care was really not the way to go. And we needed to do something
• 28:15
  different. There were also individuals that stepped up to tell about their own stories,
• 28:20
  including Darrell Kirch, who was the president of the AAMC, and talked about his own mental health
• 28:24
  challenges, which was very profound. At a large national meeting of 5,000 people in attendance,
• 28:31
  that begins to get attention. Our youth are coming to medical school now with, I think,
• 28:37
  more mental health issues than ever before, or at least we're aware of it more than we've had before.
• 28:43
  And frankly, to be a human being in the 21st century with all the continual stimulation,
• 28:50
  we're in a heightened state of alertness and almost in a stress state continually. Now we have
• 28:55
  to go out of our way to find those times to create the pauses and the grounding. So it's very different
• 29:01
  than it was. We can do a lot more things at the same time and more efficiently, but it doesn't
• 29:08
  mean that our challenges are less. They're actually greater. And the pressures on our time
• 29:13
  are greater. And two worker households are the norm now. And so I can go on, but you get the idea
• 29:22
  that it's challenging. And so I think that there is an awareness that we have to deal with this.
• 29:28
  If you ask any health executive, top three issues that you're dealing with,
• 29:33
  workforce well-being is going to be among those top three. That's on everybody's radar now.
• 29:38
  And a lot of it has to do with the work of Colin West, who you've had on this program,
• 29:42
  and Tate Chanafelt, the team at Mayo, but many others as well that have addressed that.
• 29:47
  What the Mayo group did that was extraordinary is really come up with data with numbers. We needed
• 29:52
  to really understand this, not just descriptive, but really get a sense of what does it actually
• 29:57
  look like when you look at the numbers across the nation. So in a way, I've been more optimistic
• 30:04
  about the future of medicine now than I have was 20 years ago. I think this realization,
• 30:10
  the move, for example, to bring humanities into the curriculum, you wonder, is there room for that?
• 30:16
  Yes, there is room and it's essential. The need for self-reflection, and not just through mind,
• 30:22
  body experiences, but also through narratives, through discussions, creating communities.
• 30:29
  You know, as we move more remotely and as we're using simulations and as we look at e-visits,
• 30:36
  telehealth, right, as in an in-person relationship as we were in the past,
• 30:41
  which has advantages, particularly for rural medicine. But yet what you see is our students
• 30:48
  thrive connection. We need this kind of social gathering. And frankly, it's what led me to think
• 30:57
  about mind, body, too, if you will, thinking about a different kind of curriculum,
• 31:05
  not to take mind and body away, but about a third of our class will take the mind, body course.
• 31:09
  But that means that two-thirds don't, either because of time pressures or because, you know,
• 31:14
  just the idea of meditation doesn't really resonate. And so I've been looking for a number
• 31:19
  of years for material to develop a different kind of course that would perhaps broaden the appeal
• 31:26
  and allow for self-awareness and self-reflection to emerge, but through a different context.
• 31:31
  And I landed on something which I'm happy to tell you about if something you want to hear.
• 31:36
  I do. This is a perfect segue. I'd love to hear about this course. Please share the title again
• 31:42
  or read the title to us because it's I think fits in so well with this interview. So when you first
• 31:47
  invited me to come on your on this podcast and you told me it's about flourishing, I chuckled
• 31:53
  because over this past summer, the course that I developed is called the Course on Human Flourishing.
• 31:59
  The tagline is strategies for thriving in medical school and in life. And so just to briefly describe
• 32:06
  what this is. First of all, the context for this course is that physical and mental health are
• 32:12
  critical. There's no question. But it's not sufficient. It's not sufficient to thrive. In
• 32:18
  other words, you need mental and physical health and mind-body can help us get there. It's a way
• 32:23
  to which we can care for ourselves, understand ourselves better, be more present, which we know
• 32:28
  improves well-being. But if you think about your job and your life, well, how do you thrive in that?
• 32:34
  And for that, you turn to the positive psychologist, turn to the social scientists, and you discover
• 32:41
  that there's quite a literature on human flourishing. And I'm particularly citing work from
• 32:45
  Tyler VanderWheel, who is a social scientist at the Harvard School of Public Health. And in 2017,
• 32:52
  wrote an article in PNAS, the Proceedings of the National Academy of Science, the title of which was
• 32:57
  On the Promotion of Human Flourishing. And the thesis of his article was that there are several
• 33:04
  domains that contribute to an individual or a population's flourishing, thriving. And that
• 33:12
  involves things, first of all, some key domains, family, work, education, and community. It could
• 33:19
  be a religious community, it could be just a communal gathering. And that there are several
• 33:25
  factors that intersect with that. Happiness, life satisfaction, meaning, purpose, things like
• 33:32
  character and virtue, social relationships, and the interaction, the family relationships. And then
• 33:38
  a big one, spirituality or the transcendence, thinking about things bigger than us, if you will,
• 33:44
  in the world that we live, in the universe that we're in. Some of these are very lofty ideals,
• 33:50
  and some of these are fairly concrete. But when you think about these domains, these are elements
• 33:55
  that actually impact on how one does in their work. Is there meaning? Is there a purpose? Am I happy
• 34:01
  with what I'm doing? Am I getting satisfaction from what I'm doing? What drives that satisfaction?
• 34:06
  What determines if I'm happy or not? And so with these dimensions, I decided to put together a
• 34:12
  course. And with support from the Kern National Network, which is part of the Kern Foundation at
• 34:18
  the Medical College of Wisconsin, we received a nice grant to develop this course. This is part
• 34:26
  of their framework. Their goal is to foster flourishing and character and care and medicine
• 34:32
  in general. And I'm an educator, I'm an implementer. And so my goal was to create a course that would
• 34:38
  build on that and actually deliver the opportunities for students to experience aspects of each of the
• 34:45
  domains that I mentioned in a way that would concretize that in their minds and begin to get
• 34:50
  them to think about it. And so that's what we're piloting now. We're piloting this course. It has
• 34:55
  eight sessions. They're two hours each. We started with self-awareness and self-compassion
• 35:02
  because we're so hard on ourselves and our medical students are even harder on themselves. So
• 35:06
  they need to learn that aspect of self-compassion. And then we moved to happiness, life satisfaction,
• 35:12
  and gratitude. And this past week we dealt with meaning and purpose. And next week we're going
• 35:17
  to deal with character and virtue. And you say, what do we do? Are these just broad discussions?
• 35:22
  No, there are some very specific questions that I invite the group, and we have these in groups of
• 35:28
  10, groups of students to reflect on. And then we actually do an activity that fosters that. So for
• 35:36
  example, on meaning and purpose, have a conversation. And our two facilitators also participate. So for
• 35:44
  our students, I say, why didn't you choose medicine? Why are you in medical school? What do you hope to
• 35:48
  achieve? What is the best part of yourself that you could see manifest in the career that you
• 35:53
  aspire to do? What is it that you wish for? What is it that you need? And then to our faculty,
• 36:00
  why did you choose what you're doing if you're teaching or if you're doing research or if you're
• 36:04
  delivering care? What is that that gives you meaning? And then what we do is we have them write their
• 36:10
  own Hippocratic oath. This is something that I borrowed from Rachel Naomi Remen in her Healers
• 36:15
  Art course, but we've kind of retrofitted it to this. And that have students think about not
• 36:22
  reciting a Hippocratic oath of somebody else's words, but rather their own oath of what is it
• 36:28
  that they hope to aspire and hope to receive in terms of skills and courage and fortitude to
• 36:36
  really be successful in life and to make an impact and to make a difference. Our session last night
• 36:42
  was about this. The students left their days. They said this was an amazing session that validated
• 36:50
  why I'm in a medical school. So I'm very excited by this. I can't wait to do next week. And as we
• 36:57
  unfold this, I'm going to do a training to bring 10 people to a training for three days, immersive
• 37:04
  training so that they will kind of live the course that they're then going to deliver.
• 37:10
  I see this as really expanding the offering. My body is certainly valuable, has its role. I hope
• 37:16
  to capture another segment of the class with this offering on human flourishing. It sounds fantastic.
• 37:21
  And I think your faculty development process sounds like a wonderful way of really having
• 37:28
  people live it who are teaching it. I'm also thinking about that exercise with the Hippocratic
• 37:32
  oath. You know, that is probably the first actual statement of professionalism that has been made.
• 37:38
  So a lot of this is tied into professional identity formation, which actually, in my mind,
• 37:47
  Audi is not something that you do once early on in your education, then it stays with you.
• 37:53
  It's a constant remaking, revisiting, reflection process, an iterative process throughout our
• 38:01
  career. I did want to, when you're talking about meaning and purpose as one of those center points
• 38:08
  of this course, or one of the sections of this course, maybe you can talk about why is it
• 38:14
  important that we have a sense as health professionals of joy, we could say, eudaemonic
• 38:21
  joy, and meaning and purpose in our work? What is the importance for that for us? It may be a
• 38:27
  rhetorical question, but I think it's worth all of us reflecting on that because I think it is
• 38:34
  something that sustains us and actually feeds us and that also actually allows us to serve our
• 38:42
  patients as well. Well, for medicine in particular, there are a lot of sacrifices. Sacrifices in going
• 38:48
  through the training, there are sacrifices in your time as you care for others, there are emotional
• 38:54
  tolls. For people in the trenches, the nurses, particularly, I'm thinking about the residents,
• 39:01
  many are dealing with life and death situations on a regular basis. That takes a huge emotional toll.
• 39:07
  Our societies couldn't exist without people being engaged in that activity and helping others, but
• 39:15
  we can't lose sight of the burden that it is. When you look at the plus side, why would I want to do
• 39:21
  this? There needs to be a sense of gratification that manifests as joy. It's not just I did a good
• 39:30
  thing, but I'm actually happy about it. We ask students, what makes you happy? Is it getting
• 39:37
  a good grade on a test? Is it opening the door for someone who was struggling because they're
• 39:43
  on crutches? Which one of those actually gives you more joy? We know from the data and the literature
• 39:48
  that when you perform an act of kindness to someone else, you help them, but you also help yourself.
• 39:54
  And it's a toss-up, which one is actually more beneficial? So at the end of the day,
• 39:59
  if we want society to achieve a higher manifestation than simple self-angradization or
• 40:06
  self-gratification, we have to help others and benefit the joy from that act. And so I like the
• 40:12
  fact that we talk about restoring the joy in medicine because there's so many things that beat
• 40:17
  us down. Let me take the position now of a health executive. Many of us look at the health executive,
• 40:24
  all those guys get paid a lot of money and what are they actually doing? But the truth is,
• 40:28
  it's very difficult job to manage the risk, to try and balance how are you going to run a very
• 40:35
  complicated enterprise with so many variables. There has to be more in it than monetary
• 40:43
  remuneration. That's not the driver. And Dan Goldman wrote about this almost 25 years ago
• 40:50
  in a Harvard Business Review on what makes a leader. He interviewed 200 CEOs of companies.
• 40:55
  What makes a leader? And yes, they're all smart. They're all well compensated. They're all highly
• 41:03
  motivated. But you know what the distinguishing factor was between those that were successful,
• 41:09
  that had successful companies, was the degree to which they could empathize, empathize with
• 41:15
  their workers, the degree of empathy. And that's when he developed this whole emotional intelligence
• 41:19
  framework, which is the empathic leader, not the one that falls apart necessarily when things are
• 41:27
  bad, but someone that could put themselves in the shoes of the other, understand the other point of
• 41:31
  view, and then make decisions that take things into account. Yes, as a leader, you'll make tough
• 41:37
  decisions. Not everyone's going to be happy all the time, but it depends on how you approach that.
• 41:42
  And so the same thing in medicine as you're thinking about delivering bad news. I hate that
• 41:46
  part of the job, right? Giving bad news. But then if you do that in an empathic way, in a way that
• 41:51
  the patient is grateful, thank you for sharing in the manner in which you did. The reality is the
• 41:57
  reality, but everything else that surrounds that can make the entire relationship a much better one.
• 42:05
  That's why we do what we do. And the sooner we can transmit that to our students and have them
• 42:12
  think about it with their own lenses, about their own experience, and what kind of practitioner they
• 42:19
  want to be, we're doing them a favor. And so it comes back to your first question to me. How do
• 42:24
  you go from science to education? And the bottom line is our students don't just become compassionate
• 42:31
  caregivers because they came to medical school with very high GPAs and they know how to memorize.
• 42:38
  That's not what does it. And unless we create opportunities in our curriculum to specifically
• 42:46
  develop that aspect of their personality and we model it and we work on it and we have them work
• 42:53
  on it and they do it in groups and learn from each other, that's when they'll become compassionate
• 42:58
  and caring practitioners. It won't happen by happenstance. It has to be really carefully
• 43:04
  thought out. So I think we're making progress in ways that we didn't years ago. Yeah, I agree with
• 43:12
  you. I think it's very possible to do this, to get there, partly because as social beings, as a social
• 43:20
  species, actually evolution has designed us in such a way that compassion is important. It's actually
• 43:27
  a survival. Sympathy is important. Survival, empathy, those are all important characteristics
• 43:32
  that have improved the survivability of our species. And so we're tapping into something that is very
• 43:39
  real, very biologic in a certain sense through one lens. And so it's there. It can be suppressed or
• 43:47
  trained out of us or our society and culture can push it aside for other things. But I think it's
• 43:55
  great that you're in a position in medical education that is sort of bringing this back
• 44:00
  online, so to speak. I want you to do a little thought experiment and then describe as best you
• 44:06
  can what it would be like to be a student in an encounter with an educator, a health professional
• 44:12
  educator. And that educator is flourishing, energetic, committed, compassionate, attentive,
• 44:18
  robust. Imagine what that experience would be like if you're the student from that end of that
• 44:24
  relationship. And then the flip side would be as a health professional educator working with a student,
• 44:33
  what is that experience like for you when you are flourishing, when you are committed, compassionate,
• 44:39
  attentive, robust, all those other adjectives that I use. So what's it like to be on the, we could say,
• 44:45
  receiving end of that bi-directional student educator relationship? And then what's it like
• 44:51
  on the other side being the educator and you're feeling good and flourishing? Great question.
• 44:56
  So let me start with the learner side, which is what do we know about learners
• 45:01
  encountering enthusiastic teachers that love what they do? Think about the teachers that inspired
• 45:08
  you. More often than not, there were people that really were enthusiastic. If you look, for example,
• 45:14
  what's the number one criterion for how students positively rate a teacher? Enthusiasm is number
• 45:21
  one. That actually is actually more important than content delivery and so on. So enthusiasm we know
• 45:28
  is contagious and positive emotions are contagious. And so that certainly helps. And as opposed to
• 45:36
  someone that comes in and goes, you know, I really don't want to be here and kind of is a turnoff.
• 45:41
  Where the stern educators are is a little bit in between. I think over time you learn to respect
• 45:48
  the people that were stern and very deliberate and smile a lot, but that's not the same as the
• 45:54
  folks that are engaging and charismatic and also taught you well. Those are the ones you remember
• 45:59
  and those are the ones that you want to emulate. So, you know, we learn a lot from our teachers,
• 46:04
  both what to do and what not to do. As an educator, I will tell you, I was the beneficiary of two
• 46:09
  educators. Both my parents were teachers and they were extraordinary teachers. They were legends in
• 46:14
  the school that they taught. They were different, but they were extraordinarily enthusiastic and
• 46:20
  knew what they were doing and knew that every student actually, you had to reach every student
• 46:26
  differently because not everybody learns the same way. And so I never thought I would be a teacher.
• 46:33
  You know how that is. You don't do what your parents do until you do. And so for me,
• 46:37
  I derive the greatest pleasure when I have a group of students that are totally with me.
• 46:44
  And, you know, I'll have students come to my office, knock on the door, and sit down and
• 46:49
  they're in tears and they're going, I just don't understand anything. I don't know even where to
• 46:55
  begin. And so I say to them, you know, before we do that, just tell me about you a little bit.
• 47:01
  Tell me like, you know, how did you get to Georgetown? Where are you from? Tell me about
• 47:05
  your family. And we'll spend 10 minutes just kind of learning a little bit. And I said, you could
• 47:10
  ask me anything you want before we start. And I'll get to your question. But then after 10 minutes of
• 47:16
  a connection, and I'll always find something to say, oh, I kind of know that place. And then I'll
• 47:21
  say, well, let's see. And I'll invariably, you know, they'll say, I don't understand this. And
• 47:27
  I say, well, maybe you think you know more than you do. And, you know, maybe you actually do know.
• 47:32
  And I'll ask them a question that I'm pretty sure they'll be able to answer. And sure enough, they
• 47:37
  do. And then I go, okay, so we got this part down. In other words, it's about building things up.
• 47:43
  And as I'm watching this, there's a part of me that is just chomping at the bit, because I can't
• 47:48
  wait for when the session is over. And they look at me and they go, wow, that actually really,
• 47:55
  really helped me. And all I did was just help them identify things that were inside them, but they
• 48:02
  were just covered over. They were clouded. And you bring clarity into that and you bring it into it.
• 48:08
  And in some cases, there are things that need to be explained. And great. And so and someone will
• 48:13
  say to me, I hear you, I don't get it. I said, good, let's try it again. And then they'll say,
• 48:18
  you still don't get it. And I say, we're not leaving here until I've found a way to help you
• 48:24
  to try and do this. And so it's on me now, not on you. It's on me, because I'm not explaining
• 48:29
  this right. Okay. And so that takes some pressure off. But there's nothing that gives me more
• 48:36
  pleasure than that. I remember walking into a lecture hall with 102 fever, pre-COVID, of course,
• 48:41
  102 fever, feeling like crap. And 10 minutes into the lecture, I actually don't feel anything
• 48:49
  anymore because my adrenals kicked in. I'm on a high. It's just, it just feeds my soul.
• 48:57
  Well, I have had that experience of learning from you. So I can attest to that. So finally,
• 49:04
  I'd like to know, and maybe our listeners word, but mostly it's for me, what you like to do when
• 49:09
  you're not speaking or teaching somewhere on planet Earth. And there's very few places on planet
• 49:14
  Earth that seems you haven't been teaching others or innovating and planning changes in medical
• 49:19
  education. And maybe that's what you like to do most, but what else do you like to do?
• 49:26
  So I do have a life outside of my job. It just so happens that I love my job. And I think I have
• 49:30
  the best job in the world because the school is giving me a lot of room to really maneuver.
• 49:37
  So what do I like to do? I like to be with my family. We have three grown children.
• 49:41
  We have five grandchildren and one on the way next month. Everybody lives in Miami. So we're
• 49:48
  on a monthly trip to Miami. I have contacted all the med schools down there, by the way. I've
• 49:53
  visited them all because I don't sit on a beach, but I like to cook for my wife. But my greatest
• 49:59
  pleasure is cooking for my kids and my grandkids and watching them eat mindfully because they've
• 50:06
  learned how to eat mindfully. And so they're told the first bite of anything you eat has to be a
• 50:11
  mindful bite. You need to savor it and then you need to open your eyes and tell me what you just
• 50:16
  tasted. And that is my greatest pleasure on this planet. Well, I would love to be invited to your
• 50:24
  home someday and be able to mindfully eat your food. So we'll keep that in mind, Adi. Anything
• 50:31
  else you'd like to share that we, there's a lot of areas we haven't got to, but this has been great.
• 50:38
  Really appreciate this time with you. Really, especially appreciate the time with you. I always
• 50:45
  feel enriched by that when I'm around you. So anything else you'd like to comment or reflect
• 50:51
  upon? Yes, I would actually. I first of all want to congratulate you on leading this series. You
• 50:57
  have an extraordinary talent. I don't know if you remember when we met, but our viewers or our
• 51:02
  listeners might be interested to know that the way we met was you published a paper in JAMA in
• 51:10
  2009, if I'm not mistaken, September of 2009. And it was a paper about creating a program to help
• 51:20
  primary care physicians reduce their burnout through a series of interventions that your center
• 51:26
  is well known for. And I read the paper, I saw it come out and I emailed you immediately. I didn't
• 51:35
  know you, but I found your email and I emailed you and I said, congratulations. It's amazing that
• 51:40
  they published the paper because JAMA was not known for this kinds of work. But I said, this is
• 51:45
  going to be a landmark study. And that became our friendship because then we met and we did a bunch
• 51:50
  of conferences together, but I've learned from you a tremendous amount. And I came up to your
• 51:56
  training that you lead with Ron Epstein. And so I have to say that it's been a delight to get to
• 52:04
  know you and to learn from you. And thank you for inviting me to join you today.
• 52:09
  Thank you. Thanks for listening today. We will include a summary of today's podcast and links
• 52:15
  about Dr. Haramati and other references that he made that were discussed in the show notes.
• 52:20
  I would like to conclude by sharing another exercise to support your flourishing in medicine.
• 52:25
  For this one, I'd like you to sit comfortably for the next few minutes and simply follow my
• 52:29
  suggestions as you explore ways to care best for yourself. Dr. Haramati talked about this in the
• 52:35
  podcast, this self-care element, and I thought maybe we should just explore this a little bit.
• 52:41
  So sitting comfortably in a chair, you could stand if you like, wherever you are,
• 52:46
  just making yourself comfortable. You can close your eyes, you can keep your gaze a little
• 52:51
  diffusely focused, or you can look at something. All of that is okay. And I'd just like you to
• 52:56
  reflect for a moment on what you do to care for yourself. What are the things that you engage in?
• 53:02
  They may be spending time with friends and family, maybe getting outside, taking a walk with friends,
• 53:10
  maybe reading, maybe writing, maybe listening to music, maybe simply just relaxing and sitting quietly.
• 53:22
  If you could bring one of those activities to mind right now, just take a moment to experience
• 53:29
  what's happening in your body right at this moment as you bring that experience of self-care that
• 53:36
  you've engaged in to mind. Our minds are real powerful, quite evocative of actually
• 53:44
  changing our physiology from moment to moment and simply reflecting on an activity in which
• 53:51
  we are caring for ourselves can be an act of caring for ourselves.
• 53:57
  So actually one of the activities that you may want to consider doing is simply stopping for a
• 54:04
  moment during your workday, the end of your workday, in the beginning, whenever you feel
• 54:10
  like it's called for and just reflecting on caring for yourself, on specifically an activity that you
• 54:16
  engage in that you identify as self-care. Simple as that. So I hope you found this podcast and the
• 54:25
  Simple Guided Practice useful, and I look forward to having you join us for the next episode of
• 54:30
  Flourishing in Medicine from Surviving to Thriving. If you would like to learn more about EmPRO,
• 54:36
  please visit www.myempro.com. And for more information about me and my work, please visit
• 54:44
  www.mickkrasnermd.com or www.mindfulpracticeinmedicine.com. Until next time.