Good morning, everyone. Our symposium this morning is going to be kicked off by Dr. Brandel, President of the APA. Good morning, everyone. Welcome to San Francisco. I'm practicing like I still have a teleprompter in front of me, but we're a nice small group this morning. It's such a pleasure to be here and I'm so grateful to Bruce, Anna and Tom for all the work that they've done in inspiring generations of leaders through where I first came together with the three of them at the Tarrytown Chief Resident Leadership Seminar. So and I asked them as a result of that, if they could be here to talk a little bit about leadership. I'm particularly indebted to Bruce, who suggested to me that perhaps I should take on a leadership role in the APA. And I said, well, that's a really nice idea. I'm glad you have so much confidence in me, but I think we're talking about a different person. And he said, okay. And here we are. So I just wanted to start us out this morning in reflecting on all of this with a couple of things. So I spent a lot of time being, well, I still spend a lot of time being profoundly anxious, but I used to spend even more time being profoundly anxious that somehow there was this roadmap that everybody else knew. Everyone knew like how to say the right thing, how to be calm and measured and balanced. When my own chief of psychiatry suggested that maybe I enter a physician leadership program, I thought that was a really great idea until I realized that the other person who was nominated was our good colleague, John Alpert, who's here. And I'm thinking like, how could I ever be like him? There's no way I could possibly do this. And so what I want to start you with and leave you with is the idea that leadership is like anything else in life. Getting good at it takes a lot, a lot of practice. So if we think about the kinds of challenges that we have to, that come up almost without notice and without a lot of warning and no specific preparation, it takes practice. So there's a couple paradigms about that. Even if you're really good, even if you're outgoing, you're funny, you don't get nervous in front of people. I'm actually really naturally shy, so I have to practice being able to be in a room and going and shaking hands and talking to people. You can learn how to do it, but even if you're really good at it and you have natural talent, there's been a lot of studies of how you develop expertise and how you really get good at something. And there are two books that really stand out to me. So one is Malcolm Gladwell, who talks about 10,000 hours. No matter how much natural talent you have, it's practice, practice, practice. And those who are really excellent get in. The magic number is 10,000 hours. That's a lot of hand shaking. That's a lot of being in rooms and being nervous and being in podiums and growing into one's self and one's skin. So I think when it finally got easier, today it's even fun. When it gets easier, it has to do with something about a resonance and a confidence. I know how to do this. I've seen this before. This actually is me. But the second book that people don't really talk about very much, that I found profoundly helpful in thinking about expertise and mastery is by a psychologist, Dan Coyle, called The Talent Code. And what he did was he went to, he studied athletes actually, elite athletes. And he wanted to figure out what made certain athletes really, really, really good. So he took a trip down to Brazil to some of these camps where many of the elite soccer players in the world were coming out of, expecting to see some, you know, very sophisticated facilities and plans. And what he really saw was some pretty Spartan facilities, maybe not even great fields. But what he saw was that those who developed and did really well, who excelled, who were exceptional in what they did, didn't practice differently than others did. So the good athletes, those who did fine enough, would be good at certain things and develop those skills. The athletes who became exceptional practiced from failure. So they were able to recognize the things that they weren't good at and continue to work at them and do better. Now, that's a kind of hard thing to do. It might be one thing if you're practicing as an athlete, but what does that mean for all of us? Well, I keep that with me because going back to the beginning and this profound anxiety that really held me back as in my ability to lead had to do with a fear that I wouldn't get it right, or I'd fail, or I wouldn't know how to do it. And in this leadership training, we did a lot of case studies. We had all these very successful business school professors come in. And one of the classic case studies that they go through, and there's many of them, is really a series of someone who thinks they're going into the CEO's office to be fired because something they just did went terribly poorly and lost a company a lot of money or a lot of employees. And what distinguished great CEOs and leaders were people who could say to that person, why would I let you go now? The question is, are you going to learn from what went wrong? So it applies to business. It applies to sports. It applies to everywhere in life. So how does it apply to us as physician leaders? I would say one is in order to know that maybe we didn't do our best, or it's an opportunity for learning, right, from a mini failure or something that could have gone better, you need someone who's going to tell you the truth. And that's really hard because after we work hard and we put a lot of intellectual energy into something, we want it to go well. And we often seek out the people who will pat us on the back and say, you know, that was great. That was great. One of my mentors, who shall remain nameless, I remember I was very pregnant. I could barely breathe enough to get through my talk. And I felt like it was a great feat to have even made it through. In fact, I began the talk in front of a thousand people or so in a ballroom in Boston by asking if anyone in the front row remembered how to deliver a baby because I was so uncomfortable. I needed to catch my breath. And I came down and I came off and he looked at me and he said, not your best. And I was devastated. I was devastated because I really needed encouragement at that moment. So it was definitely an affective mismatch. But what it reminded, but I did get through it and it was true. And I did go back and look at that lecture and I never gave it in a way again that wasn't great. So we can be kind. We can accept ourselves and what we can do and what we can't do, but we really need to be able to actually solicit from people feedback. So none of us, let me just end by saying, leadership is not something that's accidental. Learning how to lead in different places requires skill. It requires knowledge. It requires guidance. And one of the most important things is realizing that it's not about being perfect. It's about getting better. And it's about having people who you know, you can count on to help you do that. Right. So maybe not tell you afterwards, not your best, but how can we, how can we get through this in a way that's really positive? So how, and I would encourage all of you to think about who those people are. So the one piece of advice, there are a lot of past APA presidents in this, this room. Okay. And I'm not getting nervous. So that's like a really good thing. Okay. So I guess I'm almost there. Right. So but the idea that everyone said to me, like, who's in your kitchen cabinet, who's on your speed dial, who are you going to call? And knowing, especially being able to anticipate the places that we have the least confidence or the least experience and knowing who to count on and who we can go to for advice. So I'm going to, I'm going to stop there. But I want to say one, one other thing, because there's people of many ages and different stages of development in terms of leadership here today. And I would say that one of the things that we can do as those of us who are getting on to be more senior is to remember these lessons and think about the ways that we can be sensitive, attuned, kind, and also effective mentors in both modeling that, that small and sometimes even large missteps or mishaps are actually the way that we grow and can really help us bring the next generation into successful leadership. That's absolutely going to be needed. We'll be talking about that day in and day out over the next number of days for the future of psychiatry. So I'm so grateful to Bruce for asking me to introduce this. Thank you for putting this together and really looking forward to spending time with everyone at the meeting. Thank you so much. Thank you, Rebecca. That was wonderful. This is actually the first time we've publicly talked about the Tarrytown Chief Residents Leadership Conference. That has always been something that we have not discussed in public settings. Who in the audience has been to Tarrytown? Okay. So the Chief Residents Leadership Conference, needless to say, is unlike any leadership conference that exists. It was established in 1972 under the leadership of Jack Wilder and Byram Karasu. It essentially is two full days of sessions from Friday afternoon to Sunday at noon. There have probably been over 4,500 chief residents who have participated over the past 50 years of the meeting. Now, it's structured as an experiential learning opportunity, exclusively experiential. It's intentionally designed to emotionally engage and challenge participants. Some might say it sort of destabilizes some participants. It can happen. But we want participants to be themselves, not observers of what's happening. There are no didactics. So in 50 years of the meeting, there has never been a lecture during the conference. And we didn't want didactics really as a distraction from the experiential learning that occurs in the small groups. Over the years, there have been between two and three large group meetings, which are really the purpose of them are to facilitate the experience of the residents in the small groups, or really to enhance small group interactions. Now, groups are expected to maintain confidentiality. So what happens in your group stays in your group. And the faculty are present to observe and facilitate the group process. Now, one of the goals is for residents to rapidly establish their group and to wrestle with the challenges inherent to leadership of a group. Because the groups have no clear leadership, which is I think one of the most challenging aspects of the groups for the residents, participants essentially have to find their place in that group and what role are they going to play. The small experiential groups essentially give each participant the opportunity for leadership. Each individual adopts or expresses a style of leadership. For some, they actively try to avoid any semblance of leadership. Now, over the years, there have been several common themes that emerge. Rebecca sort of touched on them a bit. So the typical attendee is a resident beginning their year as a chief resident. The earliest themes are usually the manner in which they were chosen or appointed chief residents. And there's a great deal of variation between training programs. Some of the programs elect their chiefs by either the faculty or the other residents. Some are chosen or appointed chiefs. It's really very variable between programs. But many feel, one way or another, they were forced to be a chief or they accept the responsibilities reluctantly. So another common theme is their ambivalence about becoming a chief. While there is an intuitive awareness that they are assuming leadership responsibilities, there is little awareness of what it really means. And often fear of rising above their peer group. So the groups and individuals are really typically conflict avoidant. And members are generally not conscious or aware of the way in which they approach or avoid leadership challenges and conflict. This is usually the essence of the small group experience, to learn about yourself, become self-aware of their psychological approach to leadership challenges. There is as well, you know, learning from observing the leadership style of other chiefs in your group. And the groups can also, depending upon what's happening in the group, wrestle with issues of sexism, culture, race, bias. So research shows there is no best psychological style for leadership. And much of the best research, if you're interested in leadership research, actually comes out of the military academies, West Point, where it's their job to train people in leadership. But being aware of your counterproductive or maladaptive traits is key to success. So, you know, Dr. Brendel spoke about her anxiety. Being aware of it is really very helpful to leadership. Now, highly individualized feedback occurs in the final groups from both the faculty and other participants. So residents leave with really indelible learning about themselves. It's hard-earned. And this new kind of self-awareness about their kind of personal blind spots, their strengths, their conflictual issues, allows for the development of skills to manage conflict rather than avoidance of the conflict. And because the weekend is so intense and personal, it's really typical that attendees continue to think and process the weekend long after the meeting. Now, I attended the Chief Residence Conference, I think, in 1978. I have to say I have flashbacks of the meeting. And in the leadership roles that I've played, you know, over the years, I suddenly become aware, uh-oh, I'm doing it again. I'm avoiding, you know, dealing with a problematic individual or situation, a faculty member. And as soon as that awareness hits me that I learned that at Tarrytown, I go and make an appointment, you know, with the individual. Now, I don't want to dismiss or minimize the benefits of formal leadership training. It's a big industry, a many-billion-dollar industry. And targeted didactics or mentoring of individuals who are interested in healthcare leadership and administration, it can facilitate the development of generalizable leadership competencies. And Dr. Osdoba is going to go in some detail in our residency about how we provide that leadership training, you know, to our residents over the course of their four years with us. However, it's well-established leadership theory that places a critical emphasis on self-knowledge and emotional intelligence. Sort of the metacognitive ability to evaluate and regulate oneself as an individual and within the context of a group. This principle underlies nearly all aspects of effective leadership, including communication, conflict resolution, managing group dynamics, and coping with and learning from challenging situations. Its proficiencies in these areas is really essential for effective leadership in any community and generalizes across professional and industrial lines. Lastly, I'd like to comment on the faculty who work this conference. It is one challenging, stressful, demanding weekend for our faculty. They have to manage the experience for the residents in their group without interfering with the development of the group. Remember I said residents are confronted with groups where there's no clear leadership. So it's hard for those faculty who are very experienced leaders themselves to sit there with their mouths shut. It's a real challenge. And their goal, their role, is to sort of facilitate the group process and to have the members sort of authentically engage with each other. So they are talented and they want to come back year after year because it's a learning experience for them. And the best way I can state it, and Dr. Alper knows we had a grand rounds the other day about neuroscience. You really, for the faculty, you sort of reawaken dormant neurons or pathways in your brain that you don't use in your day-to-day work. And they really highly value and enjoy their engagement with the future leaders of the profession. So there are a number of faculty members I want to sort of again thank you sort of publicly. So let me take a few questions if people have them. Otherwise we'll sort of move on with Dr. Asdova's sort of presentation. You want to go to the mic because they're actually recording everything. So for those of us who are not lucky enough to go to Tarrytown on our faculty, is there an equivalent at Tarrytown for faculty members? Is there what? Is there an equivalent Tarrytown for faculty members? No. We've been asked that over the years. I'm not sure faculty would put up with it. It's a stressful experience, but I guess it could be in some way, you know, sort of modified. Fair enough. Thanks. Okay. With that, let me introduce Dr. Ana Asdova, who is the Director of Residency Training at Montefiore and Einstein. Good morning and thank you for being here so early. So I'm Ana Asdova and I'm the Residency Training Program Director at Montefiore for the past three to four years. And my predecessor, Dr. Weiss is here. So a lot of the work that I'm going to be presenting today has been ongoing work that's been in existence for quite some time at Montefiore. So I'm gonna really give you a lot of detail about the different experiences that we have in our residency training program to really help our residents develop leadership skills and expand their leadership capacity. So we do that longitudinally throughout the program, starting very early on in the PGY1 year up to the PGY4th year. But we also emphasize not only experiences but also didactic supervision and feedback as part of their growth. And engaging residents in leadership for us, for our training program is very important because it engages them and it gives them a sense of responsibility for the enhancement of their own educational experience. And it really prevents that divisiveness that sometimes happens between residents and faculty. And so we're all together trying to improve our program. So it starts very early on. As early as the PGY1 year, we have two class representatives per year. And those class representatives are either peer or self-nominated. They meet quarterly with me as program director and the APD, the associate program director, and they're really the voice of their class. They join program education committees and they discuss everything from curriculum, rotation, services, supervision. They're a part of the committee that creates corrective actions if there's any needed for an ACGME survey. And they actually lead groups. They lead resident-run focus groups to get ideas and suggestions from their classmates about what we can improve, what ideas they have for our training program. So they're very much involved in the administration of our residency. So there's two class reps per year, every year. They also have an opportunity to attend the departmental annual retreat, which is a leadership retreat that's sponsored by our chair, Dr. Albert, and the entire department. And there they get to learn a little bit about mission, about the vision of our department, about our plans for the next five years. They represent our training program, but they also have an opportunity to meet leaders throughout the institution. So they have a very important and significant role in our program, and two of them, every year, get an opportunity to participate in this. We also have a lot of resident-led committees. So we have two residents per year that lead one of these committees, and we have four of them right now. Diversity, Equity, and Inclusion Committee, the Wellness Committee, the Curriculum Committee, and the Communications and Public Relations Committee. And they have a big responsibility of running monthly team meetings with other residents in the residency training program. They implement and develop new programming. They sharpen their advocacy skills by having to present to me any new initiatives that they have in mind. And some of these committees also have to manage a budget, because we have a certain amount of money that we have to use throughout the year, and so they have to negotiate with me and kind of explain how they're gonna use the money and where it's gonna go to, which are all skills that we need as future leaders. Every committee has different responsibilities and different events that really enhance our program, so I listed some of the descriptions there. So that's for all years of training, but we also have a lot of opportunities for our residents to be chiefs. So we have acute inpatient, there's a state hospital inpatient chief, there's an outpatient chief, an ER chief, consultation and liaison chief, medical student education chief, or anybody that's very passionate about medical student education. So providing opportunities like this to all residents to really have an opportunity to sharpen their skills is really important. So we don't just have one chief, we have multiple chiefs. And as part of that process, I meet with all the PGY3 residents to really discuss what their interests are, where they see themselves in the future, and what their weaknesses are, so we match chiefs that could enhance their leadership skills and can also help them work on some of their weaknesses, which I think is a little bit of what Rebecca was focusing on earlier in her introduction. They also learn negotiating and advocacy because they have to meet with service directors to negotiate their time, if they wanna do electives, if they can't be at the service at all times, so we meet with them and help them tackle that, the negotiating with the service directors. They run teams, they're considered junior attending, so they really have a very important, again, leadership role in our institution. We also have a PGY5, we call it senior chief, administrative psychiatry chief. Actually, that was my role back in 2007, I think. And that role is, again, another leadership opportunity for one of our residents to be very much involved in residency training and recruitment and supervision and teaching. They go to steering committee with the rest of the department, so again, enhancing their capacity to be leaders and understanding the system. In addition to experiences per se, we also do focus on the curriculum in terms of exposure to themes that have to do with leadership, and I listed some of them. Something that's very important from our perspective is systemic thinking, so not only thinking about the product but also thinking about all the interfaces that come into play when you're making a decision as a leader. We give them an introduction to the whole Montefiore system. They come to our hospital, not everybody's from the Bronx, not everybody's from New York, so we really have to introduce our residents to the healthcare system where we deliver care, the psychiatry department, the leadership, the structures, the power that exists within our department, but also governing bodies, OMH, New York State, Joint Commission, so we don't just exist as trainees, we exist in the context of a whole healthcare system. And so we also give them an introduction to our community and the patients that we serve because they are a part of the system that we're working in. And as we progress in the years, we also have administrative psychiatry lectures and one popular one which is called Managing the Boss, and so how do you deal with your boss and how do you negotiate things and manage above. During the PGY4 year, we also have a leadership seminar that has been in existence for many, many years, and so we, all PGY4s, attend monthly because we believe that everyone is gonna be a leader eventually, whether it is in private practice and negotiating with insurance companies, whether it is in a smaller setting in a clinic, whether it's running a multidisciplinary team. So we believe strongly that everyone should have some leadership training in residency, but then the chief residents also come back another second time in the month and there we dive into their experience a little bit more and we talk about any clinical or supervisory challenges that they're experiencing in their services. So the real purpose of this leadership seminar is for them to understand the complexity of leadership and understanding their own style. These are some of the themes that we cover in the seminar just so you have an idea. Many of them are the ones that Dr. Schwartz mentioned and Dr. Brendel mentioned, very popular ones which people have not thought of before is being a middle manager, coping with transitions, how to give feedback, challenges in supervision, how to develop trust and safety with others, how do you lead a team and get people to listen and how do you say no? That's a very popular seminar for us. And so there are creative ways to do this, right? There are creative ways to have a curriculum. We do a lot of processing. Our program is very well known to be strong in psychotherapy and psychopharmacology so we spend a lot of time processing questions and encouraging the actual group to come up with solutions and answers to the complicated questions that we ask. So this is an example, what is a good leader? What do you envision in yourself as a leader? Can you reflect on experiences where you have had people in a leadership role that was positive but also negative? And then we have a discussion about this. And this seminar is led usually by the program director and then the director of family therapy who's also very much involved in our system-based practice curriculum. There's other engaging ways to learn and so we do role play, a lot of role play of difficult scenarios of a resident giving feedback, a chief resident giving feedback to a resident, the chief resident then having to go back to the service director and share their feedback. We also have a lot of role models of leadership come back and talk to the residents about their journey. So earlier this year, we have the chair of the department who talked about his own journey in leadership. We had a woman leader from one of our sister institutions talk about gender inequality and her experience becoming a leader. We also have junior leaders talk about their challenges in transitioning into leaders of institutions underrepresented groups in medicine talking about their leadership journey. So there's lots of way to learn leadership and so we try to be very creative in our approach. We also engage in fun activities with the residents. So one fun way of learning about teamwork and collaboration is doing an online escape the room. And so how do you come together as leaders to really figure out how to get out of that room? And that was very fun, especially during COVID. As part of the seminar, we also encourage them to teach each other. And again, creativity is important for us. So we have them teach each other on any themes related to leadership. And so there's some examples of things that we've done before, like playing games, requiring, again, teams and reflecting leadership style. We process what we do. So we play the game and then we point out when somebody talked, when somebody's gonna encourage someone else to do something, who was quiet, who was more active, why were you quiet, why were you more active? So we process a lot of the simple games that appear simple and fun. We really make it very educational and sophisticated in how we approach it. There's also the leadership training that our residents go through. So everybody goes to Tarrington, which has an amazing experience. And I was also there back in probably 2006, something like that. And there, there's an emphasis of self-awareness and group dynamics, experiential learning. And within Montefiore, there's also another leadership conference that our residents go to with other chief residents within Montefiore. And that is more didactic based. And so they learn about characteristics of a good leader, transitioning to being a leader, communication styles, and how to develop trust. In addition to everything that I've mentioned, there's also other little things here and there throughout the training that really help you in terms of developing leadership skills. So in terms of your clinical work, we have them run multidisciplinary teams. And so a lot of the chiefs run multidisciplinary teams, they run community meetings in the different inpatient settings. And that is a way to really engage and give the residents an opportunity to be leaders in our institution. But we also have a lot of advocacy and community partnerships. So we've collaborated with the Office of Population Health at Montefiore. And our residents visit community-based organizations. They meet and interview leaders of those organizations and then come back and present what they learned to each other. One is as a way of engaging with the community. Two, to figure out then what else can we do for those community organizations. And then eventually, there's scholarly work that comes from that because there's QI projects or initiatives that the residents then get motivated to do back for those community-based organizations which strengthen our collaboration but gives them an opportunity to be really a leader out in the community representing our institution. And so there's several, we've visited particularly this year during Mental Health Awareness Month, we've visited senior centers, day programs, religious organizations. They present whatever topic those organizations wanna hear about. And it's beautiful to really see them on, not stage because it's usually like a basement or we go wherever we're invited, but they present their material and answer questions. And sometimes the community is upset about something and they are there kind of like managing the questions and teaching the best they can about mental health. And that is a beautiful way to also enhance their leadership skills and encourage them to be community psychiatrists and activists. Of course, all of this is supported by mentorship, sponsorship, and supervision. I meet with a lot of the residents throughout the year. Every service director meets with their chiefs at least once a week. Class reps meet with me. There's a senior chief that has a very important supervisory role and I provide feedback to the chairs of committees throughout the year. We review goals and what we accomplished and we really kind of do this together. And there's also, we're lucky to have phenomenal faculty that are leaders in our communities. And so they are also very much involved in helping our residents both accomplish local skills, but also sponsor them to present in national conferences and other places. I reviewed the information that I had from our program and for the past six years, we have a lot of leaders that have emerged from our institutions. So it was a moment of pride for myself and I'm sure for Dr. Weiss who was the previous program director and she probably helped creating this more than me. But 35% of the residents in the past couple of years eventually became leaders of institutions and this is just the people that I am aware of. And when I asked our chief residents about leadership training in our residency training program, they had beautiful things to say. One of them said, as soon as residents begin on service rotations during the intern year, we have opportunities to take leadership roles formally and informally. Numerous resident-led committees and weekly didactic sessions encourage us to work collaboratively and contribute our individual perspectives. Multidisciplinary clinical teamwork, research and teaching opportunities and a system-informed curriculum enable us to work and grow within a dynamic collegial environment, developing leadership skills along the way. As senior residents, we transition roles from mentees to mentors through chiefships and supervisory roles and collaborate to learn from one another's experiences. I have enjoyed significant personal and professional growth during my years in residency and reflecting on the process has allowed me to appreciate how each of these opportunities have contributed along the way. So it's really a journey of leadership. That's the approach that we take in our training program and a combination of opportunities, lectures, supervision and mostly experiences that we then process and really help people develop the skills and the capacity that they can as leaders. Thank you. Any questions for me? Okay, I introduce Dr. Thomas Betzler. So, first, I want to thank Bruce and Anna for inviting me to be here. I have been doing, actually running a community mental health center in the Bronx since 1995. Actually, when the task was thrust upon me, this is how I look at it, I don't think anybody else wanted it, and they told us that we were going to close it in three months, and we had to figure out a way to fix it. And we did, and it's thriving, and I can tell you that what I learned at Tarrytown, and I first went to Tarrytown in 1995 as an instructor, not knowing what I was doing. I said, if I just keep my mouth shut, I'll be okay. And that did seem to work, and I just sort of learned things there and brought it back to the clinic to then try and adapt how we could make the place, from a systems perspective, incorporate this idea of leadership, of fostering young faculty, of trying to have people really find their passion, and to really try and mentor them. Like Rebecca, there's been many times when I've been giving talks and I've come down, and I'd say to my team, how did I do? And they said, well, we think you got on base, but it could have been a homer. And I was like, well, you know. So I do think having people that you can trust, that will tell you the real deal, is very, very important. Now what I think we've done, so we have a community mental health center with about 5,500 patients from a very diverse background. All of them, or 90%, are either Medicare or Medicaid. So we have this focus on how do we help this population, this diverse population. So the three cornerstones, I think, that when I look at what we do, is we look at mission, which we think is very, very important. The mission of the provider who we are interviewing, who wants to come to our center. So from day one, we kind of find the residents that are into social medicine or community psychiatry, and we want to cultivate them so that they can flourish. Recently we hired, about five years ago, we hired someone who actually grew up in the neighborhood, and said he always wanted to work there. So we tap into people where their interests are, who know what their interests are. And I think that's very important. I remember hiring and attending about 20 years ago, and she stayed with us until she died. And she asked me before she started, what is it like? And I said I think it's like being in the Peace Corps, but you get paid well. And after the first month, she came to my office and she said, thank you. That's exactly what I feel like I'm doing here. And I love it. And to the point that when she developed a malignancy, she said, can I, I want to stay on. And I said, you know, well, I don't know if you can see patients because she was very frail. So we went to employee health, and she got a waiver to be able to do some QI work at our center, because she said, I need to be here. So her mission aligned with ours. And I think that that is sort of the secret. Today we're seeing in every specialty at Montefiore, a flight, people leaving. Bruce asked me to come and talk because we're not seeing that at my center. And we're not sure why. But we are not seeing people leaving. And so I think that that's something that is very, very important at onset. When we interview someone, we actually, if we hear any kind of derogatory remarks about our patient population, regardless of their credentials, we really don't want them to blend in with us, because it will contaminate the system. The other thing is a sense of purpose. The sense of purpose for the individual is key. It's the magic that makes it all happen. It no longer becomes a job. It becomes a mission. It incorporates the mission. So it is the magic. It's almost like Mark Twain, he said, the two most important days of your life are the day that you were born, and the day you figure out why. And I think that my docs figured it out. At least that's what it seems like when I'm at the center. And I think that that can be adapted anywhere. And this sense of purpose requires you to start to really get to know yourself, which is what we develop at Tarrytown. In those groups, they start to become aware of the skills they have and what they don't have. And it also cultivates their sense of purpose. And that's what we see with the docs at my center. And then finally, the third thing that I think creates this holding environment that allows people to have fun at work and enjoy their passions. The third thing is giving up authority. Letting them, believing in them, giving them tasks, and then letting them fly with it. And certainly, it cannot violate our mission or our sense of purpose. But how it's done, there's many ways to roam. And I can tell you at our center, that's what I see. So I have to keep my mouth shut. I have to listen. So we hired a new attending who we put in charge of the intensive outpatient program. And he came to me and he said, you know, why don't we do a scatamine and TMS? I mean, all of these patients, as they get sick and depressed, they're so treatment resistant, and they're very depressed. I said, that's a great idea. Why don't we do that? And so he said, well, I said, why don't you put together something? He goes, I'll put together something and you can present it to the chairman. I said, no, you'll put something together and you'll present it to the chairman. He was like three years out of residency, you know. And so, but we supported him and we took his slide deck and we tweaked it a little bit, you know, and he was fine with it. And then he presented it to the chair and Dr. Alpert said, absolutely, we can do this. And we did. And so I think we're one of the first community mental health centers with such an impoverished patient population that actually for treatment resistant depression is doing TMS and a scatamine. And that's because a junior attending said, this is what I think we should do. And we supported it. So supporting their ideas. We had another one develop a PTSD curriculum for our therapists. We have about 30 therapists. And then now we're incorporating EMDR at the center. So always taking ideas, embracing them, instead of saying no, saying yes, and not do we have to, but why can't we? And I think having that motto of why can't we is what creates an environment where people are allowed to really flourish. Now, I gotta tell you what, our faculty meetings, it's not always pretty. People don't always agree. And I think dissension is also key in creating this environment so that people can be creative. And when they're creative, they come up with amazing things. Our attendings have developed um, they said all of our patients are dying in their late 50s. Why don't we have primary care here? We now have primary care. Why? Because the doctors said this is what we need. The people in the trenches have a voice and we listen to it. And I think that that is something that's very, very important. The other thing is, we look, 65% of our patients coming from ERs and inpatients, guess what? They didn't show for their first appointment. So we got together and said, we gotta do something. We don't like just sitting here. So we developed this open access where you can walk in anytime and you're gonna be seen. We have about 20 walk-ins a week. If you walk into our center, guess what? The likelihood of you coming back in a month is 85%. We've got the data from years. 85%. The chance of you coming back in 90 days is over 90%. So once you get to us, you're golden. But we gotta get you to us. We can only get you to us if we have open access. And certainly in our emergency rooms, we hand out cards and the docs know they can just send the patients right to our center. What does that require? It requires a quarterback. They're triaging, figuring out what is needed at the time and who needs to go to the hospital and who doesn't. But all of these ideas, they come from this holding environment where people are allowed to say and express what the problems are. The other thing that we found is that we had trouble getting bloods for our patients and we were monitoring metabolic syndrome. So we decided why don't we operate like a medical clinic and everybody who we open a chart on, we get their blood work. And we administratively then request it down the road so that the doctor can be a doctor and not chase somebody for their blood work. We do the same thing with prior auths. We have a team who are not doctors who get the authorizations so the doctor can be the doctor. We figured this out because the doctors told us what to do and they, by doing that, develop a style of leadership that is really, really, I think, fantastic. And then finally, the thing that I think is really paramount to all of this is this sense of helper's high that I know my docs get. So we have 13 psychiatrists, primary care doc, 7 nurse practitioners, and 30 social workers. And I can tell you, I've to kick them out at night. They are driven not by dollars, but by passion for the work. And oh yes, just add it on, no problem, I'll figure this out. And I'm struck by that. And why we don't have burnout? I think we don't have burnout because when you have this sense of giving that matches your sense of purpose and mission, you actually get filled up instead of depleted. But you have to be able to experience that. And I think at our center, through the work at Tarrytown, we've incorporated it into the center so that we feel that at any time we can adapt, we can change, and we can figure out how to fix or tweak something. Because I think that the healthcare system we're in now does not match for our patient population. Our patient population, social determinants of health, for them to get to an appointment, they have to have child care, kids have to be fed, they have to have transportation, and when they miss an appointment, if I don't see them, they're going to go to the ER, or they're going to go to, and they're going to miss medications, they're going to get sicker. So it's the mandate to shift it back to the outpatient so that we can stop the bottlenecking in the ERs and have open access. If you miss your medication, or your appointment at our clinic, and you need meds, and you walk in, we're going to give you your meds. We're not going to send you to the ER. So those are the kinds of things, but that's a cultural shift. I think at our center, we've gotten there. And finally, I think that the other thing that's really important is that, you know, through this Helper's High, Churchill said, we make a living by what we get, but we make a life by what we give. And that's what I think happens if you can create an environment where people can express themselves, feel empowered to make change, and take leadership roles, and champion things that they want to do. And so for that, I want to thank Tarrytown and the leadership, because I have to tell you, all of the things I've learned all of the years of going there, coming back is, how do we do this here? What do we need to do so that we can foster leadership and really help young attendings, not only stay, but flourish? So thank you. Any questions, any? Thank you very much. That was a great presentation. I just had a question about how you were able to incorporate that walk-in clinic, because, you know, typically in an outpatient setting, it's hard to do that from an administrative perspective. So, you know, did you have one designated person that became that go-to for the walk-in, or did you just spread that amongst all the providers? So it's a good question, right? Because how do you manage all of this? So we've looked at this, and about 30 to 32 percent of patients do not show for appointments. So that means we have people idle. We have a clinical manager who will triage anyone who walks in, look on the schedule and see who has a no-show, and pair it up with the no-show, to the point that when we actually started this, we're a union shop. The docs are not union, but the NPs are, and so are the social workers. The social workers said they think they're doing worse care because they're seeing too many people. They were seeing maybe six or seven a day. So we brought the—the state of New York has data on your outcomes that we don't keep. And when we presented to the union that since we've developed the walk-in, our rehospitalization rate and our ER visits are lower than the region and the state with a sicker population, and the union turned to the people and said, they're right. The data supports what they're doing. So yes, it takes a coordinated team effort. Sometimes we call an ambulance to get them to the emergency room. Sometimes they need medication and we don't know them. Rather than send them to the ER, we say, if you can prove to us that you have meds, you have bottles, is there a pharmacy we can call? We will bring you into the clinic. We will get you your meds. It's called meds before evaluation. And because what we don't want to do is send them out and hurt them. And so I think that that's the mandate. I think it can be done. I think we've really shown that it can be done. And I think that it's something that—that OMH, at least in New York State, should really think about requiring for licensing because it will stop the bottlenecking that I see in our emergency room, which is really crazy. Great. Thank you so much. Jan Wise from the UK. It's always lovely being over here and learning from what you're doing. You somewhat shyly suggested you didn't have a view on why your retention rate is better than your colleagues' system. I'm wondering if you did a deep dive into your pre-conscious. Could you share some thoughts about what may be involved in that? For me to be so—I'm sorry. Clarify that just a little bit. You mentioned that you don't lose your staff, that you keep them. Yes. You mentioned that your colleagues' system—I'll mispronounce it the UK way—Montefiore, appears not to be keeping its staff. Not just Montefiore. Globally. At least, that's my understanding. I was at an event two days ago where the induction of people into the Davidoff, which is an honor society, and people from all over were saying that they're short-staffed, that people are leaving medicine. I don't know if these are the reasons that we are not seeing people leave, but when I looked at it, when Bruce asked me to look at it, these were the reasons that I thought might be related to it. But it isn't just a Montefiore thing. It's all over, at least in New York City. That's what I know of. That's the region that I work in. I don't know. Are you guys having that in the UK? It's a massive problem for us, but we have a difference in retirement issues. We have a national HMO, the National Health Service, which has relied upon people retiring and returning in psychiatry. Pay erosion has been 38% over the last 15 years. We're underfunded. People don't wish to maintain the system anymore because they don't feel appreciated. We don't have the ability to introduce new systems that you've described. So there are a lot of problems that the Royal College is trying to address. We just don't have solutions at the moment. It's interesting because I have a lot of docs who are retirement age who stay. I had one retire a couple of years ago and said to me, Tom, I love this place. I'm going to move to Arizona with my family, but if I hate it, can I come back? I said, absolutely. Four months later, she moved her family back and she's still with us. So there is some magic to the whole, I guess it's oxytocin. I don't know, but there's some magic that's happening in our system that I can tell you. And she's a fabulous psychiatrist. So we do get people thinking about retirement, but we're not really seeing it. Hi, I'm Carol Bernstein. So self-disclosure, I work at Montefiore, so it's sort of close to Newcastle here. But I think you touched on something that is very important in leadership, and I was actually very struck since I'm new to Monty with how Tom had built this sense of connection and rapport in the clinic where they're seeing such sick patients. And I think there's a fundamental issue with trust and connection that comes with leadership. So I was wondering if any of you on the panel could talk a little bit more about how you foster that and you develop that, because I think it leads to the success of programs like MBHC and others. I'll address it a little bit. So we don't throw anybody under the bus. That's our expression. So when something bad happens, we look at it as a team. We support it. We try to figure out what's going on. Now certainly we have a quality improvement team and all of these other people also looking in. But if somebody's having a bad day, we support them. We want to know about it. We want work to be supportive and fun and not stressful. And so they do come in. I've had doctors come in. One came in crying. He told me he spent the weekend doing his charting and didn't have any time off. And I said, you know what? Take tomorrow off. I can see that you caught up. I can see you worked all weekend. And so you should take tomorrow off. So by them coming to you, you hearing it, at least from my perspective, and trying to do something instead of saying, shame on you for being overwhelmed. This is an overwhelming job. It just is. Our patients are very sick. And all the patients love the guy. And so he does a great job. So why am I going to bury him on something that I can help him with? And so those are the kinds of things I think that being supportive and not trying to try to turn anything that happens into either a learning experience or something that's positive, somebody can learn from it. And me too. And sometimes my people have to say, Tom, you can't do this. And I say, okay, okay, okay. Because sometimes you affectively have a reaction to something, particularly when it's due to patient care. And you got to take it, you got to get some affective distance before you then meet. And that's also been helpful. I don't know if you guys. I would ask the group, does anyone know of a community mental health center caring for Medicaid, Medicare patients that provides a scatamine or TMS? Yeah, it's really quite unusual for most community mental health centers to do it. But I think one of the important lessons is how important affective leadership is to any system of care. And again, throughout medicine, I mean, Tom mentioned it, the turnover of professionals is enormous. Certainly the pandemic has hit healthcare very hard. And a number of people who are leaving medicine or choosing early retirement or going elsewhere for jobs and more money is every specialty. And I would argue that one of the reasons that's happening has to do with leadership. That for leaders who engage their staff and create an environment where they feel comfortable and feel that they're effective, that they're having an impact, that they're being listened to, that there's an opportunity for, you know, just as Dr. Osdova spoke about in residency training, how we try and educate our residents to issues around leadership, you know, Tom has remarkably been able to do that in a very busy, very demanding, you know, environment that we're in right now. And I think that's one of the things that we need to do. And I think that's one of the things that we need to do. And I think that's one of the things that we need to do. And I think that's one of the things that we need to do. And when I got to Soundview at the time, Jack had been sick, which is why the place wasn't having such problems. And so I was sent over immediately because Jack had been there and I finally met with Jack to sign out the place. He knew everybody's personal life story who worked there. He was that kind of a guy. And he was the one who developed the chief resident program. Sure. Just to answer Carol's point on how do you create trustworthy relationships and communities, I think it's important to be open and genuine with your people, to have open lines of communication. Everyone likes transparency and to understand what's happening within a system. And I acquired the residency training director role during COVID, which was a particularly complicated time. And I think those are some of the things that really helped me gain the trust of the community that I was leading, even when we were still deploying them to medical floors and having them do things that they didn't want to do. So genuineness, advocacy. They know that I will advocate for them until the end. And that is something that Tom does very nicely, even though he hasn't spoken directly about it. They know that he's a very strong advocate for his people. And be yourselves, because people appreciate having somebody that they can talk to, that they can actually relate to, that will listen to their concerns, even when something cannot be done about the situation. If you listen empathically, connect with people and understand their struggles, it will help you create a trustworthy relationship with the people that you're leading, and it will move your cohort in a different direction, where you're all working together towards the same missions and the same goals. And on top of that, if anybody gets sick at my clinic, their family members, they come to my office, I call the ER, I tell them, these are family members of the Montefiore family, can you get them in quickly? And they do, to the point that one time a pediatrician met one of our psychiatrists with her child right at the door. So they do listen to us, and we're talking about a busy health care system, but they do listen to us, particularly when I insist that you don't understand, this person's very important to us, their family member's very important to us, and we really need to fast track it, and I think that's something. I also want to mention something that I didn't mention, and that is, Dr. Alpert has been very supportive of our center and the things that we're doing, and that is very key, because at any point in time, he could also say, what's going on over there? And I mean, I report to him, I give him a five-year plan, we're developing another five-year plan right now as we speak, but the point is, he has trust in us, which allows us, it trickles down, and when that happens, it's really very, very nice, and so I think that that's the other piece, because at any time, you know, everybody's got a boss, and the boss has got to believe in the mission as well as the people under you. You know, I'm curious, in terms of people in the audience, what's your experience in terms of dealing with leadership in your lives? I mean, we'll keep this, what happens here stays here. Except it's recorded, no. Just don't use names. This is a dairy child. But let me just say, you know, especially the old-timers call it Tarrytown, and it's called Tarrytown because for several decades, the meeting was held in Tarrytown, New York. The conference now is actually held at the IBM Conference Center in Armonk, and we got some flack from the IBM management because we had a Tarrytown conference in an Armonk IBM center, and some higher-up who hadn't walked through the lobby of the conference center saw, what's this about Tarrytown? This is Armonk. This is IBM. So we had to do a little bit of light rebranding, but I think all the old-timers know the places, the Tarrytown. But in terms of your lives, in terms of the, you know, what kind of maladaptive leadership have you experienced? What kind of effective leadership have you seen in your work, in your careers? Please come to the mic. Hi, I'm Ozra Noberry from Sutter Health. What I think has been affecting our center has been the constant change. There are so many interim people in the leadership. I don't think any of them were ineffective, but it just like, it feels like that you have a ship that is constantly going one side and then going to another side. It's just like even though it is not a stormy situation, but everybody is gearing the, you know, the ship to a different direction. All of them are wonderful, fantastic directions, but you feel like that you're not making as fast of a progress during the time. So I feel in a bigger leadership roles, those decisions need to be made when it comes to the, for example, we have the freestanding hospital that has 80 beds and then it is under the bigger Sutter Health system. So whatever decision is being made is going to affect the hospital and the changes to the leadership is something that I've noticed as being very challenging in general. I should mention that, and please some other people, I'd love to hear from you, but here we have all these young residents coming to the program, and I left it out, but one of the earliest topics of conversation is what's wrong with the leadership in their hospital, their program, you know, the chairman, you know, whatever. The litany of complaints about, and certainly turnover, and leaders who keep changing direction, or, you know, or keep changing. Yes? I just wanted to comment on that as well. I think you're right that that presents a real problem, because each leader brings with them their sense of identity and purpose, and so it's shifting all of the time, and each leader has their own gauge of how much control they need or don't need, and once, so that if that keeps going back and forth, it creates really chaos, I think, in a system, because you don't know what to do. Just to add to that, in terms of like the residency training perspective of that, a way to navigate the challenges of continued changes in leadership and new faculty and junior faculty coming in is that I've invited alumni to participate quite heavily in our program, so they supervise, they mentor, they teach, and then they maintain the essence of who we've always been, even with the constant changes that we have within our institution. So inviting alumni has been very successful for us to be able to continue things as we used to do them, while also adjusting to change. Yes, and I'm sorry I interrupted you. No, we're good. I'm Andrew Lancie. I'm at the University of Illinois in Peoria. An example of someone of a bad leadership, we had someone come in to take on a presidential role in the hospital, local hospital, and he came in with his own agenda, which didn't make sense to the area, the system that we were actually in. He also didn't stay very long and transition. Thankfully, our newer one came in and actually paid attention to the system and kind of learned how to learn that system. So kind of the two questions I have is one, is how do you learn that system? Do you have a good systemic way of quickly learning the system when you come into the leadership role? And then two, how do you lead when you have no power? Because I think a lot of times that's where a lot of our, I mean, I'm medical director of our inpatient units, I'm medical director of the consul liaison service, so I have several leadership roles. And as the leader, the medical director of our inpatient services, I actually worked for the university, but in the hospital. So I actually have no power, but I'm the decision maker. So how do you suggest people can lead even though they don't really have that power behind them? Well, to your first question, I'll tackle it and I'll try and tackle the second question as well. But I'll welcome other comments. It's very important to listen. And that's certainly in the chief residence conference, and Tom demonstrates it as well as Anna. You want to listen to people and not necessarily avoid conflict and try and quiet everything down and sort of paper it over because it doesn't work. And that's one of the kind of major deficiencies that sort of many leaders engage in, that they don't want to hear about conflict. They want to avoid discussions of challenging issues, but listening to what's going on and then creating an environment and a group that hopefully wants to sort of solve the issues of conflict. You do have people who want to cause conflict, right? And that's always something to sort of be aware of. But if you're not listening and hearing what people say, then you're going to have a hard time. So people have much more power than they are kind of willing to sort of sometimes exercise, right? Leadership should nurture that, to allow people who are put into a role to sort of exercise, make the changes that they feel they need to make, all right? So I've been lucky in my career to work with people who just, Dr. Karasu is very fond of saying that to be a great leader, you have to hire people smarter than you and then you let them do their thing, right? And you only step in when there's a problem. So I've always had, you know, I've always felt, hey, you know, I'm going to do this and if they tell me to stop, you know, then I'll stop. But that's one of the psychological issues that we encounter in the chief residents, you know, that they're middle managers and we're all middle managers, right? And oftentimes, you know, middle managers look to their, the people above them to sort of solve the problems and they don't, because it's kind of your job. And, you know, that's one of the kind of self-awareness issues, you know, that's sort of very important for young leaders, you know, to learn that, gee, you know, I do have more authority. I can exercise, you know, more responsibilities. And as long as I've got a good reason for doing it and I'm, you know, my intentions are honorable, you know, those are the opportunities that are a lot of fun, you know, for people in terms of navigating a system and making change, you know, because I think in effective leadership, they want to control everything. And if you aren't working in a situation, in a system where people aren't leading but they want to control everything that happens, then that's a very defective, you know, kind of environment. Other comments? I would like to say that I think your power comes from your work in the trenches, in the patient care that you see, because you're given an insight into what needs to change and what needs to happen. And then you need to figure out how leadership can hear you and listen. And that sometimes can be really an area that can be a problem. But I do think I agree with Bruce that listening to and also figuring out, like he said, you know, leaders want to be in control. By giving up control is what Bruce is saying. You hire smarter people. You hire people that you can trust to do a good job. And from that point on, they then sail. But they're not going to overshadow you, right? And I don't know when you have a leader who doesn't understand that, it makes it really tough on you and can create, I think, enhanced burnout. And I think that's what you're kind of alluding to. We have an activity that we do with our chief residents after they've experienced their services for a month that we call power grams, which is very much like a genogram but of power. And we sit with each chief resident to understand the power structure in their service and how does that attach to the Department of Psychiatry and how does that relate to the Montefiore Healthcare System. So understanding who has power in your institution that you're going to work with and the service that you're working with, who's an ally and who is not an ally for the changes that you want to make. And so that has been very helpful for them to understand their power in the context of the system that you're working in. So really being very purposeful about writing out your power gram and understanding where you're working. We always say, in the outpatient clinic, we tell the residents, don't change anything when you start, when you inherit the patients, don't change anything for the first month. And we also encourage that from the leaders, from the chiefs, when they show up in their services, don't change anything yet. Get to know the system, understand the context where you're working at, before you want to implement change and engage the people that are going to be most impacted by the change in the conversation of what you want to tackle. So those are things that we do with the residents that I think are very applicable and helpful for anybody, regardless of their context of work. Also, I'd like to say that I think by giving people the opportunity to find their way and present it with loose parameters, enhances not only physician leadership, but social work leadership. We have clinical managers who are now seating every part of Montefiore that actually started at our center and came up the ranks at our center and really learned how to handle or run with the ball, presented at meetings, feel supported, and move on. And so I think it has an impact not just on your local job, but on your whole sense of psyche and your sense of self. And I think it is hard when you don't have that or you can't get that from the person that you're working with. Other anecdotes? I actually have a question because I'm an incoming resident, so I am not yet in the leadership. But I want to know how to help my program when I am maybe post-graduate year one or two to help them empower and influence such a wonderful, healthy environment if they are not already doing that. I'll let our residency training expert... You're saying you're starting as a residency program director? I'm applying for residency this year. So I have no power, I will be part of the team. But if I want to help my team to empower such a wonderful environment that you're saying that you're doing a great job with, how can I help them to do that? Well, I think, I mean, you're going to start basically the interview trail in the fall is what I assume. And I think you have to find a place that feels right for you. And I think that is key. When I interviewed at Montefiore, it felt like a home. It felt like a place where I could be genuine, like I could be myself, and that it would really help me further develop the skills that I came in with in an open environment where I could make mistakes but also grow. So you have to be in the right setting and in the right context and with the right mentors and sponsors to really help you flourish in your leadership. So as you interview, find a place that feels right for you because that is important. If I were to work in a place where I didn't feel supported by my chair, where I could actually have a conversation and sometimes disagree with him, where I can have conversations with the service directors and express my concerns about the residents, then that's not going to work. But then you have a team of people. Once you join a residency, there's a team of people, and hopefully you'll be in an environment where there's communication, where you can be open, when they're going to be receptive to what you bring into the table. And so even though you think you have no power, you would be surprised how much power you have in a residency program because you've completed evaluations, because you complete surveys, because the program director wants to have residents that are happy, that are learning, that are growing. So there's a relationship that has to happen there. So don't underestimate how much power you have when you enter a situation. Enter with confidence, not arrogance, and try to bring your full self to the table and see how you can make an impact there. And I don't think it ends in residency. I think as an attending, when you move up the ladder, I have an amazing team or this would not fly. None of this would fly if I didn't have people I could trust and we have each other's back. And I think that's something that's really important. And I don't mean that negatively, like somebody does something wrong. It means that you can say how you're viewing the case. Even on my way here, I called an attending and said, somebody reviewed a chart and they noticed this and this and this. Can we go through what you were thinking? In a very non-judgmental way. And then she said, well, that's not really correct. And let me tell you what I did. But I think being able to be that approachable and non-judgmental in your stance is also something very important. I want to also somewhat echo what the speakers have been saying all day, but to sort of pointedly add for your question, which I think is a wonderful question. I think one of the most important things is for you to take your time, observe and try and understand why things are being done the way they are and then see how your ideas and solutions fit in over the years. So I was the previous program director. Over the years, I had so many experiences where I would get calls from the different settings about people being annoyed with the resident because the resident started in and then they immediately had some... They wanted to change how we do the records. They wanted to change the schedule. They wanted to change... And the resident wasn't wrong. They had really good ideas, but it was too soon and they didn't understand, well, why was the system doing what it was doing? And then you sort of have to make friends a little bit before you come in. So to take your time, observe, understand why things are the way they are and then make your suggestions. So I would think that's just to summarize some of what's been said. Good luck. Dr Albert, I saw you raise your hand earlier. First, I just want to say how fortunate I feel to work with all of you. I think the reason why you're all such great leaders is because you walk the walk and not only talk the talk. And people can... You know, people know that you're the last ones to leave and that you embrace the mission that they then are able to embrace. And you bring a certain kind of selflessness in terms of caring more about other people's careers than often about your own career advancement. The kind of generativity that you all bring to your roles, I think, really is the essence of leadership. And I love the question that was raised. Because one of the things... And Bruce, you said that, you know, leadership has become a billion-dollar industry and, you know, you go to the airport and every bookstore has, you know, a million books on leadership. And I think one of the unintended consequences is that a lot of newly minted graduates from medical school or residencies, for their very first job, they come to us and they say, I want a leadership role. And I think they confuse leadership from leadership title. And often they engage in this very detailed discussion about what the title will be and what, you know... And they sort of miss that a big part of leadership is not about having the title, but actually emerging as a leader. And often the person on a committee or any kind of work that we do emerges a leader because of the things that you were saying, that you want to empower, you want to add to the work of the team. And I think sometimes graduates feel an urgency to have a leadership title before they've had a chance to get mentored, have role models and to begin to make a contribution and exert their soft power on committees or other, you know, in residency and beyond. And I think the person you mentioned, Tom, who thought about TMS and this ketamine is an example of that kind of person. He put the mission first. He knew that he wanted to serve the community by giving them the same state-of-the-art kinds of services that usually are offered to patients who have greater means within faculty practices that are structured in a very different way than a community mental health centre. And he wasn't asking about a title, he wasn't asking about a raise. It wasn't about that. He just knew he had a contribution that he wanted to make. And that's true leadership. It's not a leadership title. It's true leadership. And I think that we need to try to encourage graduates not to be so anxious about getting a leadership title that, you know, that's not really what's important. It's gradually emerging as a leader and then being recognised with titles down the road. But the titles are much less important than the actual contribution. You know, as you said about Churchill, about giving. It's not what you get so much as what you wind up giving. And that's sort of the essence, I think, of emerging as a leader over time. So thank you for a wonderful... I think that's a really good point about that attending. And I have to tell you, when he first started at our centre, after the third month, he came up to me and he said, so this patient wants this, this and this, and we're very patient-centred. So I said, well, why don't we do that? And he goes, oh, I get it. We break all the laws, don't we? I said, no, we bend the laws when it's related to patient care. But we break no rules. There's really not a rule here. And he laughed. He goes, I got it, I got it. And then he sailed. It was like he got it. He could... The patient came first. If there was some sort of thing he needed to tweak, he would do. And I think that that sense of culture is really fostered. And I think it's fostered at Montefiore. And for that, I thank you. Just in closing, I think I get asked often by young psychiatrists, you know, how do I move into leadership? And my response is, you do the work. You do the work. And as I reflect on my career, and unfortunately, I've lived through, you know, the emergence of the Joint Commission and all the trauma it caused in the health care system early on, is I volunteered to do additional things, to chair committees, you know, QI, do the Joint Commission prep, all the types of things that... And just doing the work gets you recognised. Because here's a guy who's doing the work. And it's having a good outcome. That's how you really become a leader and get oftentimes recognised for that leadership. So we're going to give you the last comment. Mike Dawes, Boston Medical Centre and VA Boston. Terry Town, graduate many, many years ago. Question is really a systems question of how to approach leadership. Because working both at Boston Medical Centre, which is in some ways very similar to the institution that you're describing, and VA Boston, which is part of a national VA, there's a lot of strategies and stuff that's of our centre, of how to initiate and encourage fellows and residents to take on leadership roles when you've got some of the constraints of the systems. Your system, you know, would probably be more comparable to our BMC. But any thoughts that you have or resources within APA of how to help educate trainees as they're moving through, more the fellow moving into faculty position. But I'm trying to mentor our... I'm a Program Director for Addiction Psychiatry Fellowship and a Co-Director for Interprofessional Fellowship at this point. And I'm focusing and re-looking at how do we train folks for leadership roles, but realising the systems requirements, and depending on the job, are vastly different. But any comments and thoughts you have about that? Yes, we don't have much time, because I think our official end time was about a minute ago. But let me say something that hasn't been probably sufficiently emphasised, is a mentorship. That, you know, the APA has all kinds of leadership fellowships, you know, that people can apply for. And they'll get, you know, some leadership experience and mentorship. But I think it's very important when you recognise someone who's got abilities, to take that person under your wing and begin to sort of, you know, mentor them in the role and kind of help them move their career along in terms of, you know, moving them into positions that give them some opportunity, you know, to lead. And then, you know, helping them, mentor them. Not tell them how to do it, but to get their participation and sort of, you know, problem-solving. And to develop their comfort with, you know, developing ideas and opinions, so. I also think it's a teaching opportunity, because they're going to be going through multiple systems in their career, whether it's HHC or it's Montefiore or it's, you know, in New York City. And I think learning from each one of them and mentoring them on the pros and cons of what they're seeing, so that they can take that with them in their travels, because they're not going to be at that place their whole career, at least most people are not. So I think I agree with Bruce, that putting it as a learning opportunity is really important. And lastly, the 50th anniversary of the Chief Residence Conference takes place June 2nd to 4th. We maybe have one open slot left. So, but it's... For a resident. A resident. So thank you all for your time and attention.

leadership

medical field

psychiatry

Dr. Brandel

anxiety

Malcolm Gladwell

10,000-hour rule

The Talent Code

Tarrytown Chief Residents Leadership Conference

experiential learning

Montefiore residency program

Dr. Betzler

emotional intelligence