I'm Madeline Becker. I'm a psychiatrist. I work at Thomas Jefferson University in Philadelphia, Pennsylvania, and I've had the great pleasure of meeting our speaker, Dr. Darshan Mehta, during my journey in integrative medicine, which is sort of my other area of subspecialty besides consultation leads on psychiatry. And we have met through many years through the mind-body course at Harvard and also through the Academy of Integrative Health and Medicine, and he's also been an invited speaker to the Academy of Consultation Leads on Psychiatry and here at the APA. And he was invited by our president, Rebecca Brendel, to come and share some of the work that he does. Dr. Mehta is an assistant professor in medicine and psychiatry at Harvard Medical School. He's the director of education for the Osher Center at Brigham Women's Hospital and Harvard Medical School. He's also the medical director of the Benson-Henry Institute for Mind-Body Medicine at the Mass General Hospital and the director of the Office for Well-Being and the Center for Faculty Development at Mass General Hospital. He's also an internal and integrative medicine consultant to the home-based military program at the Mass General Hospital. Thank you all for coming here. His presentation is called Health Care Provider Resilience and Well-Being, Understanding the Wounded Healer through Neuroscientific and Epigenetic Lens. Thank you. Thank you, Madeline, for that kind introduction. All right, so we are an intimate group, as you can see, which is good. And I hope all of you will stay. So what I invite, because it's going to be a bit experiential, so that we can have it be more engaging and supposed to be just a pure neuroscience talk. So I would invite you, because we're gonna do a little bit of interactive activity at parts in the group, so if you want to just sort of come a little bit closer, or make sure you round a little bit a group of people, because we're gonna have some interactivity. Okay, so come on, come on forward, and don't be shy. I assure you, this will be enjoyable. You won't regret it. That's okay. So as Madeline mentioned, I'm the, I'm probably the lone internal medicine physician here at this meeting, and it's really, it's a joy to be here, to be with all of you, and it's because my work has looked at the intersectionality of medicine and psychiatry through the lens of mind-body medicine. And then in that, within that, I've started, over the last decade, I became more interested in understanding our own wounds as healers in the profession. And so I'm going to present a few things here. So here's what I hope to do. I want to actually talk a little bit about how we learn, because in part, if we understand where we are today, somehow we got here as providers, as health care providers, and so understanding our learning environment. I'll talk a little bit about the epidemiology. I think just so that everyone, I think many of you may know, but I'll just make it very plain and obvious as to the epidemiology. Consequences. I'm going to describe a few solutions that we've tried. Again, thinking about this, both the neuroscientific and epigenetic lens, and then thinking about future directions. And this is all going to be woven in the context of a personal narrative, which is my own. So I will share that, too. So, I don't know if you recognize these individuals. Some of you may. If not, so on the right is Dr. Lorna Breen. She was based in New York City. One of the frontline emergency room physicians at NYU. Really one of like, like, like literally stepped up. Like, who's gonna come and like work in COVID? And she was one of the first to appear. Again, really beloved colleague. Passionate, as was described of her. And dedicated to her work. Like, there was no question about her patient. Like, her loyalty to the profession and commitment and, and really, really putting patients first. On the left is Dr. Skip Atkins. He's a primary care physician at Massachusetts General Hospital, where I'm based. Again, I was based at our health center in Chelsea, which is an underserved community just outside of Boston. Again, really like the rock. He's one of those physicians that would be very active politically, would be very immersed in the, you know, in the community affairs. Was like, again, had a, you know, was one of those people, wasn't really shy of how big their panel was, quote-unquote. But, but really was committed to each and every patient. Loved, again, some, a beloved colleague. Passionate, dedicated provider. And, and what is true about both of these individuals is they both died by suicide. And, and this is the, and this is a very public story. Just so you know, this was the piece in the New York Times on, on Lorna Breen, top ER doctor, who treated virus patients. This is actually a paper then subsequently talking about the stigma that come, this was written by her sister and brother-in-law, who have created a foundation in her memory, and, and really breaking, a call to action to break the culture of silence around clinician burnout. This is a piece by Skip Atkins' brother in the annals of internal medicine. Put your own oxygen, put your own oxygen mask on first. And he writes very beautifully and poignantly, he's like, how can a doctor be loved by so many take his own life? And, and, and it's a, it's a beautiful piece as he describes as people were greeting him at the Memorial Church, the famous sort of church, right, on Harvard University campus. And then there's a written piece by Skip Atkins' colleague in the Washington Post, doctors die by suicide at a rate, so I said, here's what we can do. So what can we do? Well, part of this is that we live in this sort of culture, right? It says that really, it's quite all right. You see, at this clinic, we believe that only the wounded doctor can heal. You see, at this clinic, we believe that only the wounded doctor can heal. Right, and I, and just to think about that, for those of you who are, how, how many of you have experienced that feeling at some point? Let me just show by raise of hands here. Anyone has had that experience feeling? Yeah. Okay, and, and the idea here, you know, is to think about like, why in this, what is this about our culture of medicine is really creating this phenomenon. So let's talk about the wounded healer. What is the wounded healer? And this is actually a concept that was really, I think, expounded by Carl Jung. He talks about the archetype of the wounded healer. And the wounded healer is that we overcome the pain of our own suffering by becoming compassionate teachers and show others that they too can transcend their pain. And we transcend our suffering through the path of service, leading them to help others. Right. The third point is that we see the suffering in others, and they therefore can lead others to find ways to overcome their own suffering. But the fourth point, I think, is the one that really has struck me. It's like, they may help heal the wider ailments of humanity's shared life, but our wounds may not fully heal. Right, so it's interesting. The thing about wounds is that it leaves often a scar. And as we think about, like, when we think about the physiology of a scar, that part of the skin is often a little bit weaker than the rest of the other parts of our body. Right. So again, but somehow we're drawn. And again, I think part of this is, and I think it's very, we see this concept in, or often in the military, why people sometimes go to the military or become, join the services to attend to their own wounds. But they feel like this is the space that they can do that through that. And again, and for many of us, our journey into medicine is often, is part of addressing our own wounds. But then it gets compounded because we see the pain and suffering in others. And that may, again, those of you heard, I was very struck by the opening reception by Ashley Judd's talk, because how openly she was speaking about her wounds. And I was just, it just was, I was looking around in the audience that how many people were like, I think in some ways we're just like either perhaps identified with some of their own wounds, maybe had not addressed. And you could see some people, just if you looked at the body language in the crowd, like some people were just like, oh my God, this is too much for me. I don't know if I can, you know, and part of it is because we may not have addressed our own. So again, in thinking about the wounded healer a bit further, Carl Jung states that one does not become enlightened by imagining figures of life, but by making the darkness conscious. And when I give a similar talk of this to radiologists, I say, yes, that's what we do every day, right? Make the darkness conscious. But on the right is the Greek figure, Chiron. Some of you know the mythological figure, Chiron. That Chiron was this demigod who was immortal and also was the quintessential healer. And in a playful fight or with Hercules, he was badly injured. And in that injury, it was so much pain that the only way to let go of his pain was to let go of his mortality. And that was the story of Chiron. But then on the bottom right, this is a picture of two Japanese figurines. And you can see one is holding the hand of the other in this picture. But what you don't know about this is that they're both healers. And so if you reflect upon your own journey, how often have you been held by one of your colleagues? Or how often have you held the hand of one of your own? Again, something to think about. Like, have we created that culture in our profession of medicine to do that? So let's talk a little bit about burnout. So let's talk a little bit about burnout. And burnout, again, is a syndrome. And it was conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions. There are feelings of energy depletion or exhaustion, increased mental distance from one's job, or feelings of negativism or cynicism related to one's job, and reduced professional efficacy. So burnout refers specifically to phenomenon in the occupational context. And it really should not describe experiences in other areas of life. Now, that's, I think, important to reflect, is that oftentimes burnout is correlated with other clinical phenomena. But in and of itself is not a clinical phenomenon. It is really considered an occupational phenomenon. And this is important, in part, because we often will label, right, someone's like, you're burned out, or I'm burned out. And they may be a reflection of something that's happening clinically. And so when we think about what does burnout really mean, I think this is important. But there is something that's interesting about burnout, as people have now tried to understand. Obviously, it overlaps quite a bit with clinical syndromes. And some of this is reflected here. When we think about the epigenetics of burnout, it turns out that they've now identified different receptors that are upregulated. So one of them is the glucocorticoid receptor. And it's displayed. You can see there are different methylation patterns in chronic stress and depression. And there's an overlap. So these include areas of the amygdala, the locus coeruleus, the hippocampus, and the prefrontal cortex. And then sort of the operating system that kind of connects off of all of these is the anterior cingulate gyrus. There's a serotonin transporter gene methylation that was also similarly affected in stress, depression, and burnout. And what we know is now that work-related stress and depressive symptoms are associated with different brain-derived neurotrophic factor genes, so BDNF methylation patterns, in the same human sample. So again, our environmental factors will affect what we are seeing now is the methylation factors of the genes that are promoting these neurotrophic factors. And this is, again, we're at such early stages of our understanding in this. But I think we're beginning to say that who is most susceptible to these phenomenon of burnout? And we're looking at these. People are going to be, in the next five to 10 years, we'll see this whole new uptick of looking at methylation patterns. But again, I think from a very practical perspective, I mean, this is very, I think it's important to understand academically. I think, again, the lived experience is also important to understand as well. And the lived experience is that we have occupational stress in our health care profession. Occupational stress refers to the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker. And this is, again, this probably became much more evident in the pandemic. And we saw during the pandemic that there are different factors that are intrinsic to the job. For example, safety, right? If we didn't have personal protective equipment, you can imagine, I mean, some of you experienced it probably directly. But we know just from a societal perspective, how much increased stress and associated anxiety was elevated due to these factors intrinsic to the job. There's the role in the organization. Who's doing what? And again, for us in our hospital, it became most evident as who is going to clean the room after that patient with COVID was either had passed away or had been discharged home. And that became an important factor. There's other factors, including do you have mentorship, for example, and how do you get promoted? There are organizational factors. So for example, as many of you experience electronic medical record, or how many hours are you working on the job beyond the regular work hours? So again, and then finally there are things like relationships at work. If you did not like who you worked around, that makes it hard to be at work. If you're spending a significant part of your lived experience, awake experience, amongst the environment where you just don't feel good, or don't feel supported, or don't feel seen, that makes it very hard. And again, we see these themes emerge over and over, especially as we, especially through the pandemic. But now that we are sort of in this post-pandemic period, we're seeing this even become more, even more prominent. And then that affects the individual. And we see different factors at the level of the individual. It affects our, there are also potentially extra organizational factors. So for example, if you're going through a life transition of any type, like going through a divorce, or a birth of a child, or a death of a loved one. And then ultimately, that can affect your own individual health. And again, leading to both factors that lead us to either leave the profession, as we're seeing quite often now, or not be optimal at the workplace. So we are seeing, in the United States currently, one physician dies by suicide every day. That is the rate. And it is well-published. This is a statistic published by the National Academy of Medicine. They actually haven't repeated this. It's actually an older statistic, but they haven't repeated this. But it is, this is still what you see on the National Academy of Medicine website. This is two times the rate of the general population. And to put it in context, in perspective, this rate is either equivalent to, or greater than, the rate of suicide that we have seen or observed in veterans with post-traumatic stress disorder and traumatic brain injury in the military. So obviously, the absolute numbers are much greater in military populations. But the rate is about, we're on par with that rate. And you can see that there are alarmingly high rates of depression, about just under 40%. We see that even 24% of ICU nurses have symptoms that are consistent with the scales. Like if you use this ESD for PTSD, it is seen in the same level as someone who is diagnosed with PTSD. And then, again, we're seeing, again, this affects across the role groups. There are some gender differences. We see the rates higher in women than in men, you can see. But they're both high. But you can see that the rates are much higher in women than in men. And it does disproportionately affect individuals who come from marginalized and BIPOC backgrounds. In addition, again, we're seeing, this is obviously looking at sort of the disastrous consequences. There's also, like, you show up to work. It's called presenteeism. And you're not really present. So there are many people who come and show up to work, but they're not really there. And then, obviously, if you don't show up to work, that's also problematic as well to a system. So obviously, there's a human cost here that is important to understand. But there's also an economic cost. So in the United States, on average, it's about half a million to a million dollars of cost or investment into one physician, based on the amount of Medicare dollars and such in the training. And so if you can imagine 400 individuals are lost, that's a cost of anywhere between $200 to $400 million annually. So not to say that money matters, but I think we also want to make sure that there is an economic cost. When we think about return on investment, when we're investing into our own, that even in what ways are we trying to protect our own as well? And I'll just say, well, what happened during the pandemic? And this is just, again, not surprisingly, rates of burnout went up. You can see, literally, it skyrocketed. At our institution, at Massachusetts General Hospital, our rates of burnout were at around 40% consistent with the national average. And then post, just recently when we measured it, they are just under 60% of our physicians having systems consistent with burnout. And you can see this. So this is an unbelievable statistic. I mean, just think for a moment that the majority of people who work around you in the United States are burned out, right? I mean, just think about that for a moment. That is remarkable to just think about. And again, the United States is much more, I think, open about dialogue. I think if you come from countries from other, if you come from, if you're a physician who works in another country, there is less data available. So we're obviously, but we can only imagine that if you have fewer resources and you're dealing, again, in the pandemic, such that the rates are even higher then. Now, the question then becomes, well, did we pick the wrong people to come to the profession, right? Maybe we just did a bad job of selecting the wrong people to enter medicine. But it turns out, we actually did an amazing job picking the right. They're much more resilient than their age education matched peers. So we actually picked the most resilient individuals. You can see this is on burnout. They're less burnt out, less depressed, and overall just healthier emotionally, socially, I mean, mentally, emotionally, physically. Overall sense of well-being is much higher amongst graduating students compared to their. So it turns out we actually do a great job picking the right students. But then something happens as they go through this process in medical education, right? And then, again, it goes back to this notion of the wounded healer, right? Like, again, if you think about how did, you know, what attracts someone to go into medicine? And there is often, if those of you, if you've sat on, or if you remember when you wrote your personal statement, you know, no one, and I've sat on admissions committees, both at the student level and at the trainee level, and no one ever writes that I go into medicine because I want to make money. I've never seen that ever on a personal statement. I was like, I want to make money, and I want to make lots of it. And that's not a motivation. Now, you will often see that in other professions, like, say, on the business side, or they will, I mean, I'm saying in a very blunt way, but in a very polished way, say, yes, there is a, you know, maximize profits, or this and that. Like, we don't say that, and typically, most of us won't say that in medicine. But somehow, when you think about the environment, learning environment in which they are in, and who is role modeling for these students, you can understand, like, these pressures, like, some of this is now seeping down. And again, there are factors that, again, there are systemic factors. For example, cost of medical education is high, right? So again, a factor that, when the average medical student debt now exceeds 200,000 in the United States, that's a, again, that's, for most people, that's more than a mortgage, right, or often, or maybe it's, I live in Boston, so it's like a quarter of a mortgage. But it's a, that's a reality that students have to deal with today that wasn't present before. And again, that's an example of something. And we know that there is a lot of overlap now between alcohol use disorder, depression, and burnout. You can see that there's this intersectionality of all of these, that people who have symptoms that are consistent with burnout have high risk, are at much higher risk for alcohol use disorder and alcohol dependence and for depression. Now, I just wanted to think, you know, just reflect for a moment, again, when you thought about, when you think about the learning environment and what happened post-exam. Those of you, you know, if you attended, and for many of us, when we attended medical school and then after a major exam week, it was a sort of a weekend or a week of debauchery, right, that often would follow the exams. And that's still true today. If you look at even in most medical school environments, it's interesting, like we talk about, like we actually have no, very little language that we use with our students and learners about well-being as a part of building, you know, as part of the evaluative component. Like, how do you stay well after, as you go through an evaluation as a part of your clinical training? And as you can see, what's happening over time is, as I mentioned, they start off quite, they actually, most students are not burnt out when they enter the profession. Over time, that shifts. And there are obviously periods, this is, you know, medical education is changing where now many medical school students enter the clinical phase a bit earlier than perhaps many of you may have trained in. But if you look at this, they never, they don't really end, even at the end of fourth year, the final year of medical school, where it's like a nice, relaxed time, you never quite get back to where you started. You can see, like, they just don't, so then that keeps going when you enter residency. And then if we look at a mental health clinic, I mean, the student health clinics at medical schools, what are the common reasons? Well, it turns out it's probably what you see in any other clinic in a general psychiatry practice, right? This is probably the ratios of patients that you would see in a general psychiatric practice, right? Mostly depression, anxiety, adjustment disorder, ADHD, you see eating disorders and substance use disorders. And probably in this similar sort of proportions as well. So for that, you know, what do we know about the medical education environment? We know that students experience intense stressors and pervasive perceived mistreatment. You can't really, they can't actually learn to resolve normal development psychosocial crises of identity and intimacy. So like, who am I and why am I doing this work? And if I'm struggling in whatever way, am I allowed to actually be vulnerable with someone else? We actually don't create often, we haven't. Now, that's, everyone's like, that's changing. But historically, we didn't do that. Their lifestyle and psychosocial sacrifices. Again, even if you think about like, you know, even medical conferences that we attend, including this one, like we think about like, how do we, you know, now here, there's a nice, I saw there was like this nice little spa area where they had sort of a mind and body sort of wellness. I don't know if any of you went to that space, got your chair massage here, but they have this nice space here. But in general, like that's not a typical, you know, conference environment. So again, you think about like, what are the site, you have a lot of lifestyle and psychosocial sacrifices. There's becomes this shift where we move from this altruistic space, right? That's values driven to a cynical and hedonistic orientation. And that shifts over medical training. And that, I think, because it's becomes very discordant with why we entered the profession that it really results in significant elevations, increases in depression and anxiety, right? Is that whenever there's a mismatch with our values, it's hard and you can't reconcile that. And you don't even have a space to reconcile that with anyone. And there isn't a diversity of coping strategies. There's a lack of diversity of coping strategies and they're not, and whatever they have, most of them are not good. And we, again, I think you just reflect on your own experience. And this article by Timothy Wolf, it appears that though graduating medical students are worse off psychosocially than when they entered as first years. And I think that still holds true today. And here's the clinical consequence, I think, that is, to me, one of the most worrisome is that as you see increased burnout, these are reported errors. I actually made it reported that I actually made an error and a student will say, I think I made an error more. You can see that as the rates of burnout, it's not just errors, these are number of cheating or dishonest behaviors, right? So as rates of burnouts increase, the number of cheating or dishonest behaviors actually increases, right? So if you think about when you've cut corners, I mean, we've all cut corners, right? There are times like, I can just get away and not do this at this time or this time. And then do you tell or tell someone that you cut a corner? Well, and when does that happen? And again, it's very strongly correlated with rates of emotional exhaustion, depersonalization, which are two of the three domains of burnout. So this is what many of us feel, right, sometimes. This job has cost me my health, my family, and my soul, can I get a receipt? So, and again, I just wanna, I think I just wanna just pause for a moment and say, here's what we know. Burnout is high, it's high for everyone. It has tremendous personal and professional consequence. So that led me to think, well, how do we actually improve this situation? So we've established the problem, how do we actually improve the situation and what policies should we change? So I'm gonna pause for a moment here and I'm gonna lead us in an experiential exercise. If you'll allow me, we're gonna do a brief guided meditation, okay? So we'll get a chance to reflect and just pause for a moment. So if you'll indulge me for a moment, I'd like to invite you to do, it's just to feel comfortable in your chair, wherever you are. And as you feel comfortable doing so, just allowing your eyes to gently close. And if you'd like having a soft gaze towards a spot on the floor or chair in front of you. Letting your hands rest in your lap or on your knees. And taking one or two deep breaths, just to notice where your own breath is. And bring your own awareness to a triangular region that is surrounded by the bridge of your nose, the edges of your nostrils, and your upper lip, and simply noticing your own breath as it passes through that region. Perhaps it may be fast, it might be slow, maybe deep, or might be shallow. Perhaps you may notice the gentle touch of your breath. And as you reflect on your breath, what I invite you to think is, for a moment, what allows you to feel whole? What allows you to feel whole? And if you've closed your eyes, allowing your eyes to gently open. All right. So I'm going to just invite you to just, whatever came up for you, we're going to just hold that for a moment, and we're going to reflect on it in just a minute. So now I want you to think about what is resilience? And resilience is a person's ability to adapt successfully to acute stress, trauma, or more chronic forms of adversity. Resilient individuals are tested by adversity, and they continue to demonstrate the adaptive psychological and physiologic stress responses, or what we call psychobiological allostasis. And allostasis was a term that was coined by the late Bruce McEwen. Most of you, I imagine, are familiar with the term homeostasis. We have sort of, in a given moment in time, there's an equilibrium, right? Dynamic equilibrium. But allostasis refers to when there's a stressor in front of you, you actually are able to mount the stress response. So remember, the stress response in and of itself was not a bad thing. Actually, it was necessary for survival. We actually need it. If a bear is in front of you, you don't want to sit and meditate, right? That wasn't going to help your survival. But when that stressor is not in front of you, are you able to return back to regular, sort of your baseline physiology? So you're able to move, and then return back. And what happens is when there is increased allostatic load, so if you hit constant hits, you begin to stay in that stress response. So the good example, I will say, is that for those of you who drive, someone cuts you off and you're on the highway. And you can notice that just, for some of you, maybe you have that rage come in front, right? And you realize, how long does that last? And you're probably thinking, you know, that person, it's happened, say, everyone's safe. And that's still sitting with you, like for moments, minutes, for some people, hours, right? And you'll even see that some people, actually, they can't let go. And that's where we see that road rage. They just start to keep going. They just start to keep going. I just saw those of you, if you've watched the recent Netflix dark comedy Beef, that sort of begins on that premise, right? And so just thinking like that, and actually, it's a beautiful demonstration of two individuals with tremendous increases in allostatic load, and how far it takes them. And I don't want to give away the premise, we haven't said it, but that's enough, I think, I think that it really like, this was like, oh, wow, this is exactly what we're talking about. So what is the neurobiology then of resilience? It turns out that we all have sort of these pre, you know, whether it comes from our genetic predispositions, how we grew up, our other sort of environmental factors. So there are these pre, what we call pre-trauma, so trauma being the act of something happening to you, resilience factors. So those that have a larger ventromedial prefrontal cortex, hippocampal volume, there's a greater activation of the emotional regulatory regions, like the prefrontal cortex, the hippocampus, and there's less activation in the threat response in the regions like the amygdala, and the anterior cingulate, sort of the anterior cingulate circuit as well, and the locus coeruleus, where epinephrine and sort of norepinephrine sort of come out of, in terms of, are activated from those regions of the brain. But then there's the peritrauma factors, right, so at the time of trauma, that predict later resilience. So that includes structural features in the hippocampus, perihippocampus. Again, you're going to see that similar to pre-trauma, the decreased amygdala and the increased hippocampal, perihippocampal function factor are associated with resilience soon after trauma. So when trauma happens, like what actually predicts someone recovering faster, returning again back? Again, this is that flexibility we talk about. And I think of this as more of the neurohormonal flexibility. We often think of this, we often use cognitive flexibility and emotional flexibility, but there is sort of this neurohormonal flexibility that people, like you move into these spaces, ramps up, but then you come back and return back. And again, these are, again, you can see these are recent papers that have been published. Again, this language is relatively new, especially in, certainly in our field of mind-body medicine, but even in psychiatry of like, what does it mean to be resilient and what does that look like in the brain? And I think we're, again, people have chosen to divide up into these sort of pre-trauma, peritrauma. And then what happens down the road after the trauma is gone or the inciting event is long gone? And so stable individuals, they're the core affective regions that predict resilience, whereas higher associative networks flexibly adapt following trauma. So initial trade-off of the default mode network, right? Many of you are familiar with the default mode network, which actually is highly activated in terms of as a negative emotional response, but then followed by long-term benefits. So you actually, you have an initial trade-off of this engagement and then it disengages. And so those individuals who have the disengagement of the default mode network have a better ability to, are correlated with greater resilience. So again, I show this all because many of the approaches that we have seen now in, certainly for mind-body practices are associated with the similar regions of the brain, which look at the prefrontal cortex, the hippocampal volume, and again, lower amygdaloid volume. Well-being, again, another word you're going to hear a lot more of now. You see it's a multifaceted definition, right? So there's a presence of positive emotions and moods, and they include things like contentment, happiness, and absence of negative emotions. And there's depression, anxiety, satisfaction with life, fulfillment, and positive function. And again, people are now thinking of well-being is also dynamic in nature, right? So if you have tremendous challenges, psychological, social, physical, that predicts burnout. But if you're not having enough resources, I mean, if you don't have, you have too many resources and not enough challenges, you're actually bored, right? So again, we are in this dynamic. Well-being is dynamic. So we enter, we want to be challenged enough and have resources to meet those challenges. But if we're over-challenged or under-challenged, that also carries consequences. And I want to just point out that it turns out physicians are both, you can be both resilient and burned out. It's sort of like, as we learned that you can have both positive and negative emotions. You can actually be both. So the highest resilient physicians are burned, can also have high levels of burnout. And the lowest resilient can also be, I mean, the lowest burnt out individuals are highly resilient, but the highest burned out individuals also are quite resilient as well. Now there is, you can see a step graded, as resilience decreases, the burnout levels increase. But again, it is possible to have both. And again, just as we thought, and the physicians turns out are on average more resilient than the average age gender match population, but they're also more burnt out too. And that's the thing. So we see both. So I actually became interested in thinking, then this leads to like, well, what are solutions that we create then? And for me, that became this exploration into first thinking about mindful awareness. And the thing that I became most interested in is that, how do we actually know where we are? I mean, if you don't even have awareness of where you are in the moment, then you can't really do anything about it to begin with. And so I began, this is a beautiful paper by Ron Epstein, who talks about mindful awareness. It's to become aware of one's own mental processes, listen more attentively, become flexible and recognize bias and judgments, and thereby act with principles and compassion. This is a beautiful paper from 1999 in JAMA. And so it's the ability to observe the observed while observing the observer in the consulting room. So do you know where you are in relation to the other when you're with someone? Are you aware of that? And are you aware of what you're bringing to that? And are you aware of what the other one is bringing, other individuals bringing to that environment right there? And this is something, this mindful practice, something that requires mentorship and guidance. So again, similarly to how we used to think about how we interview patients that these are, some people are just better at and some are not. It turns out these are actually skills that you cultivate. And in this way, it requires mentorship, it requires guidance, it requires curricula. And again, this is something that we're learning that requires the same. And the reason why it does is because what makes medicine so special and difficult at the same times that we, as you can see, because of these multiple traumatic hits that we experience in medicine, which again have epigenetic and neurobiological consequences, it transforms not only the patient, but us as providers. We're also a profession that meaning and values underlie a professional behavior and commitment. So if we're going to integrate this in a professional, under the rubric of professionalism, becoming better professionals into personal identity, it requires a safe learning environment. And then the last point here is that we often have a general commitment to healing and service. And when that is lost, it becomes difficult. When the notion of why we are in this profession is lost, it becomes difficult. And why now? If we don't do this now, it's much harder to do this later in one's career. And I think this is one of the things that I've come to appreciate in working with students and trainees that we have to start early. So Dennis Charney and Steve Southwick sort of described the 10 factors that contribute to resilience. And it's a book that he talked about on resilience, but I've outlined them here for you. The first factor is optimism. It's the belief that there's something, that things can be better. And again, those individuals that have that belief that things can be better predictably are more resilient. It's also about facing our fears. And again, this is a fundamental adaptive response, to really counteract the negative effects of the stress response. So we're able to face our fears again. And that comes also in this, not just doing it alone, but also being able to do it with others. It's having a moral compass. As I mentioned, when you are aligned with what you feel is doing what is right, you are actually more resilient. Now, it could be different for different individuals of what is right, but when your actions are in alignment with that, that is actually a factor of resilience. Spirituality, that refers to this idea of being connected to greater than oneself. So if everything is just about our own selves, again, that becomes hard to do. And hard to deal with. And we're seeing that when we lose that sense of being connected to something greater than self, whether it's in community, whether it's a sense of meaning and value, the sense of what I'm doing can impact many people, and we lose that sense, that becomes, again, hard. Social support, again, the idea of being... One of the things in the pandemic we learned is that we had forced social isolation, right? So we lost that support. And for many of us, that was hard. And for some people, that had very catastrophic consequences. Role models. When resilient people have role models, they have people that they want to emulate. I want to be like they see that. But they also have the flip. They also have people that they don't know, like, I don't want to be like that either, right? And they can identify that. Like, I actually don't want to be that. And so you have both. But having both. Physical exercise. Madeline spoke about the value of physical exercise the other day on Saturday, so I won't belabor that. But we know that physical exercise is important as part of resiliency. Mental exercise. Again, you think about when you're in your practice of medicine, and you have that challenge, and you're trying to figure out what's going on here. I'm an internist, so we're always geeks about differential diagnoses. That actually feels good. You feel stimulated, right? You feel that positive sense of well-being when you have those mental exercises. Flexibility and acceptance. The idea that not everything can be fixed. And that you're able to understand when to accept. It doesn't mean resignation, but you understand there's a sense of strength. This is not something that we want to fix. But we want to have flexibility to shift into a space of acceptance, which is a space of strength. And we see that oftentimes. Many of you, I imagine, had these experiences with people who are at the end of life. And you're like, wow, they're celebrating their end of life. That sense of celebration. And you're like, wow, I feel empowered. Even though it may be a sad moment, but there's a sense of power. And then finally, meaning and purpose. And I think we, again, when you lose that sense of meaning and purpose, and that's one of the greatest predictors of burnout in physicians, is a loss of meaning and purpose. When you lose your sense of why you're in the profession to begin with. And I think we see that in physicians more and more. So this is now a shared responsibility. This is a shared responsibility of the providers, like there's individual, there's a responsibility of the institution creating the environments, and society at large that create the expectations of how we're to be, right? And we're seeing this constant conflict. I live in an institution that's filled with all these mergers and acquisitions. If you work for any large institution, you see all these, and how much turmoil it's creating on the physicians. Because, again, they feel, you'll hear this expression, like I'm just a cog in the wheel. And I think that sentiment is one that is shared across all types of healthcare professionals. Victor Zhao, the president of National Academy of Medicine, has written extensively now about this sense of main sort of initiative, and their organizational level responsibilities. So if you think about where you work, especially, how are these activities actually, how is well-being thought of in an active way, and in a very systematic way? So do you create space of safety for clinicians to really understand their distress? Do you integrate, is there a designation at the highest level of the organization of someone whose responsibility is to attend to the well-being? And how much actual resource are they putting into that office or chief wellness officer or that set of individuals to actually carry through that mission? But there are also national responsibilities. Is there funding? Are we studying this? And this is not just feeling good. It is, but it's also about we want to be just as rigorous in this as we are in other. So again, when we think about now building solutions, they're understanding what reduces the negative inputs, like internal conflicts, stress, time and energy demands, and then what promotes the positive inputs. There's psychosocial supports, social and healthy activities, mentorship, intellectual stimulation. So what I want to now invite you to do, if we did have this, is going back to our meditation. What allows you to feel whole? So what I want to invite you, just for a couple minutes, we're going to practice some generous listening here, which is where the speaker really gets to speak and the listener's job is to listen. And listening means not to say, oh, that's my idea, too, or that's what I feel, too, but to be really fully present. If you notice that urge to come up like, that's me, notice it, let it settle, and just be fully present. So if you can, either in groups of two or three, just find a partner around you. And just, when you had the, what allows you to feel whole, have you ever shared that with someone? And so we're going to practice sharing that. So, all right, let's do it. And I'm going to give you a cue to switch. So again, find, just huddle up with someone just near you. Don't overthink here. And let's invite, and one of you choose to be a speaker. And we're just going to spend a couple of minutes here. Right there. OK, so I'm going to invite you to find a nice place to pause again. And we're going to return back to the larger group. If you want to, you can appreciate or give an appreciation to your partners or team. And just a quick reflection, and if someone wants to just go to the mic. What was it like to be the speaker? What did it feel like for you? Anyone? We're supposed to go to the mic, so I'll just invite you to go to the mic. Just a word or two. Yeah. So it was definitely a feeling of vulnerability. It feels, we definitely have these thoughts, but in that moment of mindfulness and thinking critically about what makes me feel whole and what I value, sharing that with others definitely, I think, reveals more about myself than maybe my colleague may not know otherwise. So definitely a feeling of vulnerability. Thank you. Thank you for saying that. I'll ask the other side of the question. What was it like to be the listener? I think listening to what people, what makes them feel whole. I mean, I think it was actually quite interesting, because I think we all kind of had similar things, even though one would expand on one particular thing. But it all kind of seems to me that people have the shared family, friends, jobs. But also, obviously, what, on a deeper level, sort of wanting to help people or sharing memories. So listening to that kind of made me think for myself. Yeah, I kind of share those things as well. Even though you look at it, OK, you say family. But what exactly about the family is these other things, sharing memories? Yeah. So I think reflecting on what makes one whole, I think it's a good thing. Yeah. Thank you. Yeah, I just kind of got warm and fuzzy when I started listening to everybody else talk. It kind of made me feel happy for some reason. And it actually kind of made me feel a little bit connected to them. And I kind of then, reflecting on this, maybe that's kind of what makes me feel whole, is actually being connected to someone else. Wow. Beautifully said. Thank you. So again, you just realized that this was just literally 90 seconds each of you had, roughly? And just say that even in 90 seconds, very profound insights, both as a speaker and as a speaker. Oh, yes, you want to say something? Yeah. Thank you very much. It was very interesting. I was just talking to my colleague about the resilience you talk about Viktor Frankl, the one that really survived the concentration camp and has a book about man's search for meaning of life. And unfortunately, in our profession, we lack that element of resilience that you mentioned, the spirituality. I think, I hope, you just dealt a little bit more into the religion. I mean, I don't mean that any particular religion, but I think in resilience, people who are resilient, they believe in a system. Whatever the system is, very, very good. I mean, there has been a lot of study that the neurobiologists went to the community of the people who are living 100 years or more, and they never had dementia or no cardiovascular disease and found out what the hell these people are doing. And one of the things they found out, that the first thing that was these people have a very firm belief in a system, whatever the system was. And as you mentioned, the connection with the community, that they were part of the community. The community was so strong that if somebody was sick one day, the entire community knew that this person was sick, and they would go and found out about that. And exercise, and these people are highly active. They do work, whatever the work is, whether they are, you know, whatever it is, they are really constantly working that. So it is very interesting that we are the healer, but it seems that we are not really following. I mean, including myself, don't have much of a belief system, really. But as you mentioned, it is so important to have something that at the time of difficulty, you can fall back and try to say that, you know, I need really help. I need to reach out. Yeah, thank you for saying that. And again, we brought up some points that I'm going to actually bring up in just a minute here. So thank you for saying that. It's very true. So again, I just want to just show you that sometimes we think that we need hours and hours to feel connected. We let go. And I'm not saying that time isn't important, but it's, again, even in this brief moment, just how much sense of, you heard words like vulnerability, sense of connection, sense of being, like the sense of idea of even spirituality here comes up even in these brief, even in such a short amount of time, right? So I wanted to share with you now what we tried at Harvard Medical School, because this is sort of came, you know, I got a call from the dean. This is about five years ago. The student says, we need to do something about well-being. Our students are suffering. Can you do it? And I may not have funding for you, but we still need you to do it. So I'm not joking, let's put it this way. So of course, we said, so why has that happened? Harvard Medical School got dinged by the LCME, which is the licensing body, 12.3 element. A medical school has in place an effective system of personal counseling for its medical students that includes programs to promote their well-being and to facilitate their adjustment to the physical and emotional demands of medical education. So there's a requirement of all medical schools in the United States to have something in place. And if they don't have it in place, they get, where is it? You have now, we're going to come back and I think they give them like three years. We'll give you three years to figure this out and we can come back and if you don't have it, then they get even a bigger ding, right? So obviously no one wants to be in those shoes, so they call us. So they had stuff in place. It's not that they didn't, but they didn't have the programs in place. So we created sort of this, initially it's evolved. I'm going to show you the earlier iterations. The idea was like, be well, be able to get help and stay well. So get help was somewhat in place. Like you always have sort of the crisis hotlines and the things, but the idea of being well and staying well. And so, and it has to be acquired. That's the other thing. It has to be required. All students have to do this, which is again, very interesting. You can imagine students being told that you must do this. It's not an easy position to be in, especially at Harvard Medical School students. But we tried and what we did is we created this elective experience. Initially it was a required experience. Then we shifted into a modeled sort of, some of it required and some of it elective. And we had faculty. It turns out faculty came out of the woodworks because it turns out a lot of our faculty have interests in these things. It's just, they were never invited to come and take part. And so, for example, healthy nutrition. So like their faculty, like some of you attended, like Dr. Uma Naidushi, the professional chef. Oh my God, there's a physician and a chef all in one. No one knew that it's even possible. So that healthy nutrition. Creative arts, we had like writers amongst our faculty and poets and other types of, and then we explored things like even the simple, like doodling. It turns out doodling is a very relieving activity just to be able to doodle and be invited to doodle. And so that was the example. So we created different workshop opportunities for students to engage in. Obviously mindfulness and imagery to facilitate perspective taking. Like how do you actually use, like we just, as we modeled, we did a little bit of mindfulness activity here. How does that facilitate perspective taking? And creating, again, skillful practice. The idea behind all these things was being, creating opportunities for skillful practice. That there's something that they can take with them afterwards. You know, we taught them different types of meditation. This is an example of two different forms of meditation. And the one on the left is open monitoring style of meditation. And the one on the right is focused attention style of meditation. Mindful movement. So again, our students, turns out, were quite advanced in their understanding of mindful movement. More than the faculty were. Like some of them came, like yeah, I'm actually a yoga teacher trained. You know, I've been doing this for like many, so we actually invited the students to help facilitate some of the sessions themselves. But also, we also had experts too. And yoga, tai chi, and other movement-based exercise. Even just, you know, going out and like, how do you do the five minute quick exercise while you're studying, you know, your anatomy, for example. So this is an example. It has evolved. We actually then had to pivot in the pandemic. Because everything we had experiential, all of a sudden had to turn virtual. And that was hard, to be honest with you. Like, it's hard to like, I mean, you can do as much as you can virtually, but you lose the intimacy that you can have when you're in, or you like, the sense of community becomes different. And we had to understand, like, how do you create a new sense of community virtually? And no one had ever done, like, no one even knew how this would work. And it's interesting, it's lost some of its steam, to be quite honest. And we had to shift then, well, how do we keep the steam? We lose the faculty, and just keep it as a peer-to-peer. Like, students still engage, like engaging with others. So we make it a peer-to-peer coaching model. So we actually shifted it from a faculty-led model to a peer-to-peer coaching model. And that was one of the shifts we had. And again, this is still an evolution. Literally, on Friday, I had a meeting with our dean, one of our deans, associate deans, and we're talking about what's the next phase look like now, now that we're returning back? And no one knows. I mean, we were like, literally, we got a clean slate. And we have to put it somewhere in the curriculum. Where do you want to put it? Do you want to put it in January? Do you want to put it at the beginning of the year? Do we want it? And the problem is that many of these efforts, most medical schools, it happens right in the first year. But remember, medical school in the United States is four years long. There's no sustained, you can do it all in the first year and say, you check the box. But they're still dealing with the poor role modeling when they're on service or in the wards, and they don't have a space at that time, right? So the question is, how do you have sustained activity? And these are questions that we're grappling with. I hope some of you have answers here, but we're in that space. But at least we're trying to address it at this point. So the story to be determined, to be seen. Well, now, in my other head, it was mentioned is the Office for Well-Being. Well, what about faculty? We got to take care of them too, right? And we learned that they were obviously going through burnout. So I was just, this was not timed with the pandemic. It's just that I got this role as Director of Office for Well-Being, a newly created role at our hospital. And then the pandemic started. And even though my job was supposed to start April 1, I remember it was Friday the 13th, March 13th, everything went into virtual mode on that day. And so we started, and I tried experiments. And what we are doing currently is sort of not to do too much, but try to have different offerings that get at the different dimensions of resilience that I mentioned to you. So we have Monday morning meditations. So every Monday for the past three years, I've led a meditation. This morning at 5 a.m., I had a meditation here for our hospital. It's all virtual. Anyone can join. It's actually, we opened it to all the hospital community. So it's not just limited to just faculty. Because on my end, it doesn't matter who, like, it's like, oh, you're not faculty. You can't come to meditation. But we lead this, and it's under, and then we thought, well, how do you create more community and sense of inclusivity? And people said, well, and I can't, I have my Monday morning meeting. I can't do Monday, but I can do Wednesdays. So we started, okay, Wednesdays. And this is where we have guest leaders. So we, it turns out there are a lot of people interested in this. And we were like, people were coming out, like, you know, every Wednesday, we have a different lead. So they hear different voices, a sense of inclusivity. People have a sense of expressing their own creativity. And again, people who have experience guiding and leading a practice. And every, our Wednesdays have been tied up from, like, if you ask me today, when's our next Wednesday where we need a leader? It's gonna be at the end of August at this point. So, like, people, like, we have everyone. And we're able to even support their time. A very token honorarium for, you know, we give them basically, like, $50 for guiding. But it feels like they get a sense of appreciation for their time, and they're actually providing a service to the community, right? So again, sense of service is important, right? It's a way of giving. We've actually created a formal TED Talk series. It turns out, like, people have amazing stories. And when we were like, oh my God, I didn't even know this was in it. Again, just earlier today, I had another meeting with my, like, we, and every month, we've been able to release a TED Talk. And this is a formal. You can go to TED.com. You can find TEDxMGH. But what's unique about our TED license is that it's only available to hospital employees. It's only internal. We actually are not permitted to be external. And part of it is to create a sense, like, this is our community. And when you have that sense, like, oh, this is my community, I was like, oh, wow. But these are stories you can see of how people handle challenges through innovation, resilience, vulnerability, connection. We've had different voices. You can see there's diversity of individuals, of role groups, of stories. And each story is about 10 to 12 minutes long. We, again, people love, when you create a space, people love to share. And we have 26,000 employees in our institution. These TED Talks have been viewed by roughly about 5,000 different individuals. So it's a pretty, like, wow, this is actually, people have viewed these. And it's actually, and people didn't know, like, these other colleagues lived. Or they even saw, like, that's, I've been working with that person for 20 years, and I did not know even that element of their life. And it's just, it's another experiment. It's an experiment of creation of community. So what becomes, to a community, becomes aware of its own, is the experiment, right? When you become aware of your own, like, what happens to a community when it becomes aware of its own individuals? And again, just showcasing different ones. This is, like, a chief of Endocrine shares how his personal and professional life intimately intersected and how he deeply values what he's learned from his sisters, whose developmental conditions spurred his passion in genetics and the richness of what it means to be human. Again, remembering, like, what brought us to medicine sometimes in the first place and creating a space for that. We've created small grants. These are grants of up to $750 for faculty to help defray the cost of professional training around resilience and well-being. We don't actually know what you want, so why don't you tell us, and we'll fund it. And it turns out the average request is not even $750. The average request is about $500. So people are asking for less than what they can ask for. You remember, those of you who do grant writing, make sure you over-ask for it, because you know you're going to get less. When you ask, people actually ask for less. And again, we've all said that when the chairs, we tell the chairs, oh, these are in your department. We've had a couple of chairs who say, actually, you don't need to fund it. I want to be able to fund it, because I can say that I supported my own faculty. So again, you can see this creates a small culture change when they say, oh, it's my faculty member. I want to actually support it. Again, so it doesn't take, again, I have a small budget. This is not like hundreds of thousands of dollars of budget. We have a small budget that we can do this, and we elected to do it in this way. We're part of a resource page that we've created. And it's in the process. That's always being updated as a part of the hospital community. And then lastly, we have these fun Fridays where, again, refreshing mid-day work from physical, mental, creative activity. Again, different voices. We didn't even know what talents people had. Again, journaling, as you can see, doodling, the joy of haiku, and different people. One of the most unique ones is one of these well-being grants that we had. People wanted to learn how to use Dungeons and Dragons to create community. And that brought out a whole new group who I never even knew existed. There was a whole different group that came for the Dungeons and Dragons one. So again, these are just small experiments, and we're learning to see its effects, but just wanted to share here. We have a lecture series on well-being. Again, to bring the academic piece, last year we had Dr. Victor Zhao, the president of National Academy of Medicine, just speak. And these are examples of other ones that we've had as well. And this fall, we're having a surgeon at MGH who's been very public in the academic spheres about our own journey with substance use disorder and what it means to be facing into the stigma of a prolific academic surgeon dealing with this. And then we do individual consultations as well. Again, this creates a space that is separate from clinical spaces. And part of the thing is that sometimes people just don't know where to go. It's like, there's so many reasons I don't even know where to go. And part of the office's role is to help do that. And then we try to do skillful practice. For those people that want to teach skillful learn, we've developed this in my other hat as a Benson Henry Institute. We offer this to our faculty community. Here is an example where we focus on postdocs. We focus a lot on clinicians. But in our institution, we also have researchers that are non-clinician. They also are burned out, too. And so we created a resiliency program for them. And again, this is an eight-week curriculum based on the model developed at the Benson Henry Institute. And you can see this also had experiential mind-body exercise as well. And in here, just to show some metrics, again, this is a pilot. This is the PROMIS 29 instrument. We saw improvements, decreases, again, in anxiety, depression, and fatigue, and in sleep disturbances, and improvements in social participation. We went from the well-being index, which is a score predictive to its predictive burnout. We went from 3.9 to 1.7. Again, these are just pilots, but just show that it did have interesting pilot data for longer things. And again, a lot of positive quotes. But I think we're in here. You can see people developed a sense of skillful practice. It's amazing to get a more concrete understanding of familiarity, relaxation, and resiliency. And I hope to maintain all the things I've learned. So this is, again, sometimes what it feels like, don't do this, do this, don't do this, do this, and you got to do this and that. And I think sometimes one of the things that we can do is really help anchor people in a particular space and help them find the tools that they need. And that's where you have to be personalized in these recommendations. Again, I don't want to make sure I wouldn't be, I can't do this talk without saying from a policy instance, there are systems issues that we have to always pay attention to. And my focus has worked on the individual side, but I have colleagues who work on the systems level side, too. So they have to go hand in hand. So I want to make sure I say that explicitly. It's like, oh, no, we're not here to focus, but both have to happen. Because systems are made up of individuals. And so we have to work on both at the systems level and at the individual level. But again, as we think about students, we're trying to design curricula, employ strategies, create assessments, provide and promote mental health promotion and suicide prevention initiatives, which has been a big effort at Harvard Medical School. Physical health promotion initiatives ensure safe cultures. Again, this is about safety, psychological safety, and then training. We need to have training. And it's really creating a new culture that includes a culture of belonging, respectful inclusion, and diversity, because we know that learning environments are not free from hostility, exploitation, unequal treatment. And we want to create a more innovative and representative workforce. The AMA, the American Medical Association, has also talked about this. And again, I think the key space that they've played, at least an important, is really funding organizational science around well-being and really moving it at the national level. And then finally, there's a National Academy. And this just came out this year, early this year, about their priority areas. And this is, again, there's a whole book that they've written on this. But just the chapters are each of these priority areas. And you can see here all the seven priority areas. In these last few minutes, I just want to take a moment to just share my personal narrative, as I mentioned to you. So again, part of it is like, well, what's the next word you're going to hear? And it's going to be flourishing, probably. What does it mean to flourish? We're moving from resiliency to flourishing. And again, this is an article in JAMA by Tyler Vander Veel and others on reimagining health as flourishing. But in my personal journey, I had to learn about what it means to first discover helplessness. And this is about nine years ago. At the time, I was going through, my wife at the time and I were going through planning for a child. And we had to learn that in order to do it for, in our case, we had to go through IVF. Those of you who have either had to go through it or know people who have got to go through it, it's an emotional roller coaster. There's a hormonal roller coaster that, obviously, women have to go through. But then also, the partner is also with them in that journey as well. And it was on the heels of having lost, in that case, my wife had lost her mother the year before to an illness. And so we got excited at the outset because in our journey of IVF, we learned that we were having twins. And these were twins. They were just excited. It was all of a sudden, we lost an important family member. And then all of a sudden, we were gaining this. And at the time, as a physician, the perils of going to appointments is that you know a little bit about the signaling and the body language. And it was a high-risk pregnancy. So when we had to go to frequent ultrasounds, at one ultrasound, the tech comes in. You saw that look. I was like, oh, something's happening. So they go back. And then the attending, the radiologist, comes back in. It's like, we want to just let you know that your twins are dealing with this condition called twin-to-twin transfusion syndrome, which is a condition where one twin is getting too much blood and the other one's not getting enough blood and has to do with unequal distribution of blood in the placenta. And there's only this treatment for it is this really sort of I think of the wild, wild west of surgery, where it's like placental surgery and they get a laser and they kind of guess, if I zap this vessel, maybe that'll re-equilibrate everything, essentially, is what happens. So we went, and we had to get that done, and the procedure went well. And this was at about 20 weeks into the pregnancy. But then a week later, my wife went into labor. And it was the hardest feeling, because I held these two twin boys in my hand at the time. And there's nothing you could do, because you learned at that moment, I became a father right in that moment. And I was totally helpless. I couldn't do anything except to learn to let them go. And then that was my learn. And it was a huge, hard loss for both of us. It was different, though, because for my wife, she had this growing feeling of children in her. And for me, it was like in the moment. I held it, and boom, boom, that's what I just became this. And then I had to learn to let go. So then it made me, as we ultimately went through the process again of IVF after taking a little bit of a break, and that was a difficult pregnancy for other reasons, but that we all had our daughter at that time. And we still had these other two sons that predate. So she had these older brothers that in our minds, she will never know them. But it turns out that children are actually amazing teachers. And our daughter taught us that it's quite possible to create new meaning, even in loss, that you can actually have both grief and joy at the same time. And what do I mean by that? Well, I learned about the power of ritual. And again, going back to your point about faith, faith is a lot of ritual. But in this case, this is a new ritual. Because every February 9th, we celebrate. It's a birthday of our sons. But if you've ever seen a child, if a child loses balloons, they start crying on their own. But if they willingly let go of balloons, it turns out it's a joyful place. They're like, I'm letting it go. So every February, we have these two balloons that we let go. And you can see just this tremendous joy. And I was like, wow, in my space of grief, she's having tremendous happiness. And you can have both. Both things can exist at the same time. And we continue that ritual. And it allowed me to also reclaim my sense of faith. Again, going back to your point about faith, this became a space of faith, the balloons, representation of faith. Faith comes in different spaces. It also began a space of thinking about, where do I find my support? And again, one of the things I do when I work even with others is to think about, where do you find your support? Do you even actively think about it? Where are you giving support? How are you receiving support and learning to ask for support? So here's what I've learned. And then it is like, well, I need to really find new meaning and purpose. And this is adapted. So first is a sense of belonging, that those who have a strong sense of love and belonging have the courage to be imperfect. In medicine, we're taught to be perfect all the time. And an idea is that learning to be imperfect. And from that, evolving into a space of greater purpose. And that's pillar two, purpose. So when you have the sweet spot of when you're great at it, you love it, the world needs it, and you're paid for it, and you hit that, that's where you find purpose, when you have all of that. And for me, I learned that, actually, in the pandemic, where I was able to like, I didn't even know what I was doing. I was in this floating hospital that they created in Boston, and I remembered my sense of purpose. But then I think, where do I find my support? And so obviously, for me, it became my family. I ended up going through more loss over the years as I went through a divorce. And not because we didn't work. As partners, we learned that this was, we had our journey, we learned we had to move in different directions. But that's still hard, right? When you lose, have a sense of loss. So learning to find support. Just thinking about how our children, and this is my nieces and nephews, and then friends. When you're in, we sort of isolated, so I learned to sort of come back out. Mentorship. Some of you may recognize Greg Frischione, who spoke here. He's my director, and we went on a trip to India where we were giving a talk at a meeting, but it was one of my most joyful moments to take my mentor and go on a trip with my mentor and have that time. Like, where do I find support? And then learners. Just being around students, having that youthful energy where you're always inspired, and you can inspire, right? And having that space. So that's been a great thing. But then the next pillar is thinking about transcendence. And I think transcendence, again, being connected to something greater than the self. And for me, it was about reclaiming my own faith, and having those sense of what does it mean to believe, again, and how do we create spaces to believe? And then finally, the fourth pillar is storytelling. Being able to share your story. So when you share your story, or you have that space of sharing your story, and in my case, I feel privileged and honored that I have spaces to share my story. And this is sort of honoring this year, on this February 9th, choosing in a different way to share. And what it garnered in my peers and in there is that was, to me, I can't even, I'm truly grateful. And I'll just read this really quick. I know we're just right at time here. But it's hard to imagine how fast nine years have passed since our boys, Om and Brent, entered and left this world. I often think about the many moments we might have had as father and sons, and how they would have been these amazing and protective big brothers to their joyful little sister, Asha. And yes, I do honor that feeling of loss. It has kept my heart soft and allowed me to be vulnerable in love. And for that gift, I am ever grateful. But the wisdom of children never ceases to amaze me. And just as that tear fell down my cheek this morning, Asha burst into my room, said, happy Om and Prem day, and gave me this big hug. And I'm also reminded again, joy can be present on this day. So as I hold my children in my hand and my heart, to see a world in a grain of sand and a heaven in a wildflower, hold infinity in the palm of your hand and eternity in an hour. And it turns out, I didn't even know this, that in my own space of worship, I actually have two matching idols that I didn't realize I've added for this video. And that day, this year, which has been, I really go, wow, there is a representation. So how we find peace is amazing. So, all right, I will end there. Thank you. Do not be afraid. You've been fooling around with alternative medicine, have you? I have been. And the meaning of life to me is to find your gift. The purpose of life is to give it away. So, thank you to all of you for staying here. And, yeah, please reach out. So, yeah. Thank you.

healthcare provider resilience

neuroscience

epigenetics

wounded healer

burnout

resilience strategies

medical education challenges

mindfulness programs

peer-to-peer coaching

storytelling

integrated well-being

Harvard Medical School