A: Hey guys. Welcome back to the podcast. I am Amanda.
L: I'm Laura.
K: And I'm Kendra.
A: And today I am unreasonably excited because we have a special guest here. Dr. Greg Guldner will be joining us today to talk about organizational wellbeing. We met him at the American College of Emergency Physicians meeting in October at the Wellness Section meeting. And he was recognized for his work when he was co-residency director at Riverside Community Hospital's Emergency Department. They won the 2022 Emergency Medicine Wellness Center of Excellence Award. And if you don't know what that is, I had to look it up. It's an award for instituting wellness and resilience at an institutional level. Currently, he's the Vice President of Academic Affairs for HCA Healthcare. He works on optimizing the work and learning environment for their 300 plus residency programs across the nation. We're so excited to have him on today because while we work with what you can change for yourself right now, while you're waiting for your institution to do something, he actually was able to do something on the institutional level. So if this could catch fire and spread, like we would so love that for all of us.
So you're going to want to share this episode with your wellness directors, your chief medical officers, and anyone else who has influence over how your hospital is run. Thank you so much for joining us, Dr. Guldner.
L: Yes. Thank you so much. And we just wanna know a little bit about you. Can you just kind of tell us about your background, your training, whatever you want us to know about you.
G: Sure. Well, thank you first of all, Amanda and Laura and Kendra. Appreciate the offer to be on your podcast. My background is a little bit unusual for medicine. I started in with philosophy and psychology, as an undergraduate, majors. Went into a PhD program in clinical psychology right out of undergrad and had interest from the beginning kind of in the wellbeing space. Now I left my PhD program, after a few years of working as a psychotherapist, and left with my masters. Went to Stanford for medical school, and that's when I started really recognizing the problems in wellbeing even then. That was the late 1990s. Finished medical school, went into emergency medicine, and then left the emergency medicine residency right into an academic emergency medicine position. I was an associate program director initially, and then moved into program director position. Then actually got deployed with the military in 2007 to Iraq and Afghanistan. Came back. Had my own workplace burnout, I would say. Left academics, for various reasons, and went into community practice for about eight years.
And then in 2015, we got an opportunity to start a new residency program in Southern California at a big hospital, a community hospital that saw about a hundred thousand patients in their ER a year. So it was a very busy ER. And what was unique about this opportunity was that I would be building it from the beginning.
And my interest in wellbeing allowed us to try to think, “what would we do right from the beginning rather than all the stuff that gets concretized in other programs and very hard to change? How would we start a program including not just emergency medicine, we were a new teaching hospital, so how do we create this environment right from the beginning and see what we can do?” And then I ended up being program director for that and DIO for a while. And now I have this new position with HCA Healthcare.
L: Wow. So what did that look like when you decided to create this program de novo? How did you even go about doing that?
G: Sure. Well, first of all, I, and forgive me if I tread on anybody's favorite topic here, but my experience had been that most of what had happened in the last 20 years for physician wellbeing had failed. Certainly my colleagues and most of the people I would talk with would say the same. It kind of started with this concept of, in the late 1990s of, what's wrong with physicians? Why are we falling into this workplace burnout problem, and what personality traits are driving workplace burnout?
And so we ended up with 20 years of lots of, kind of individual interventions trying to fix the physicians. And I didn't really get a lot of sense that they were working very well. And so, one of the problems I had had is, I felt like when you look at the literature out there, almost everything's written by physicians. And I've always figured, you know, with my prior degree in psychology and my interest in psychology- why are physicians trying to answer a psychological workplace burnout issue? We can do a lot of things, but I think sometimes we get a little bit, perhaps, arrogant and think we're gonna solve this.
So instead, what we did is we went to the organizational psychologists at Claremont Graduate University, which is a university just down the street from us, essentially. It's about a half hour to an hour drive. And Claremont was one of the two major universities that positive psychology started out of. So positive psychology, you’ve probably talked about, I imagine. Marty Seligman, PhD is kind of the founder. In 1998, he was president of the American Psychological Association, and so he's from University of Pennsylvania. But the other person that really was the second person involved in positive psychology was Mihaly Csikszentmihalyi, PhD which is that super long name that's always hard to spell. And he wrote the book Flow. He was out of Claremont.
So we engaged the organizational positive psychologist there at Claremont and said, “Hey, help us out here. How would you build an organization that's really trying to support physician well-being, as apart from, you know, let's do and put a yoga den in and, you know, all these kind of things that have been happening without much success?” So they helped us out right from the.
L: So what were some of the suggestions that they had for you as you're developing this program?
G: Yeah, I, I must say I come out of the clinical psychology world, which, you know, I usually consider that as taking people in the minus 5, 6, 7, 8, 9 range and bringing 'em to zero. Like fixing problems. And the positive psychology side really looks at it very differently. And they look at the things that people who are already flourishing do and try to apply those to, to organizations and, and move people more towards the, you know, plus 10 range.
And so , when I started talking with them, I was a little initially skeptical. Especially around meaning. In fact, when they talked to me about meaning and the importance of meaning, I said, “well, that's all great. You know, we can measure meaning. So what, what do I do with that? I can't change meaning.” And they literally laughed at me and said, “There's lots of abundant ways of changing meaning and having an institution and its leaders influence meaning.”
And so, when they came to us, they really had two large theories that we're using. One is from Bakker and Demerouti who are organizational psychologists, and they use a theory called Job Demands-Resources, which is kind of simple on its surface at least. Simply looks at what causes workplace burnout. And it's, I'll call it, it's opposite. It's not quite its opposite, but workplace engagement. And they look at this and say, it's just a balance of work- job demands to job resources. And it somewhat explains why all these mindfulness and resiliency things have failed in workplace burnout. Because the biggest variable is really job demands. So you need to address job demands. And so for us, it moved away from satisfaction related to, you know, individual traits and things like resiliency and grit and so forth, and saying, “well, you know, we really just need to focus on job demands and the environment and move that away from an HR or workflow space and put it into the wellbeing space.” And say, “this is really the most important thing, for workplace burnout.”
The other big theory they used was from Self-Determination Theory, which, you folks just went over a nice- I listened to your, your podcast. It was excellent. Very, very well done. I think it was two parts. And self-determination theory is a very well grounded theory on really what motivates people. And so the question is how do you develop a work and learning environment that supports, rather than thwarts, the three main psychological needs which are: autonomy, belonging, and competence? Some people say relatedness instead of belonging, I just like the ABC part of Autonomy, Belonging, Competence. And so those are , the broad directions they sent us in when we first started.
L: Thank you for your comments about our podcast on self-determination theory. It just is such a simple, easy way to be able to look at problems and identify what psychological need may be not being met, and target that. So what would be your suggestion for an institution to help develop some of these needed senses, especially, like, of competency. Even though I feel like physicians, especially- emergency physicians, we go through a very specific directed training. We come out; we feel like we're competent, hopefully. But sometimes still when we're at work and we're overwhelmed with too much to do and not enough resources to do it, we might feel that that competency need is not being met. So how does an institution help develop that?
G: Yeah, it's a really good point. I used to joke that as emergency physicians, you have to decide where you'll fail each day. You can't win on everything. Something will fail. And I would say that, you know, our institution has certainly moved in a very positive direction. We started in emergency medicine and then breached it out into the rest of the graduate medical education. And our CEO Jackie Van Blaricum has been fantastic with this. She has essentially bought into the entire self-determination theory background. And so when you have a C-suite level capability to at least understand the belief structure… So Shanafelt, in a paper, was talking about what his definition of a culture of wellness is. And it's shared beliefs, shared values, and shared social practices that are so ingrained nobody questions them anymore. And that's really what a culture is. And so she and the rest of the C-suite at our institution has gotten to a point where, for good reasons, they believe that developing work environments that support autonomy, belonging, competence leads to the individuals flourishing and having high workplace engagement.
And so that step one is just getting everybody on the same page that maybe we move away from or at least supplement things like resiliency lectures and massage chairs and pizza parties. And those are all fine. They do create a positive emotion in most people. I like to go to pizza parties. I like to go bowling, but it doesn't change the work and learning environment at all. So you're great when you're off at the social event, and then you go right back into the same work and learning environment, and nothing has changed. So, getting to the point where people have the same shared beliefs is number one.
And then how do you work on, you know, what are valued. And those could easily just be things like: autonomy, belonging, competence, you know. It goes very close together. First, you believe they're important, and then you value them. And there's ways of valuing them as an organization. And finally, you have to create social practices around those things. And I can talk about some of the stuff that we do to do that. So it takes those three things, and over time they become ingrained enough that people are just recognizing them and not criticizing them anymore.
L: Yeah, we would love to hear specifics about what you guys have been doing.
G: So, yeah, I will say, we have had a very successful pilot in terms of the evidence. So one of the main things I wanted to do coming into this was really approach this from an evidence informed background. And so we started with the pilot, which is our institution, but we have done, now, nine waves of research confirming the relationship between these variables: autonomy, belonging, competence.
And then, the big other one is meaning. And then also some of the stuff that coaches like you three will help work with, which is psychological capital. And that's an internal resource that's self-efficacy, hope, resilience, and optimism. And those are things that organizations actually can support and help develop but often are developed through individual practices. And so, we studied those relationships to the things that we care about, which would be workplace burnout. It's somewhat opposite workplace engagement, which is this very positive work-related state of mind. That's people essentially wake up in the morning and want to go to work. And then we also measure depression as well.
And so what we've found over those three years, and we had about 2,800 responses from residents, is that those relationships held across all three years. And, and so we've got pretty good evidence. And that wasn't intervention, that was associational, but at least on three years, including into covid, those relationships held really well. So we have pretty good background, at this point, to believe that if we do this on a broader scale with larger institutions, and perhaps over more national scale, that we’ll make at least some movement more than what we've had before.
So with that being said, we have had the pilot with Rich Ryan and his company. Scott Rigby and Rich Ryan have a company called motivationWorks. Those two are the, probably the most cited psychologists, certainly Rich Ryan cited psychologist today. And they now have an implementation program where they are implementing their own theory of self-determination. And so we've partnered with them, and they've come and done some teaching with us at Riverside, and with others. So that's kind of where our background, in terms of where we're at, from an evidence-based standpoint. And then I'm happy to talk about, you know, specific types of things, depending on which direction you wanna go here.
K: Yeah, that is absolutely amazing. How can we sign up to be a part of the additional pilot? We’re volunteering our institution. But yeah, Dr. Guldner, we'd love to hear about the specific examples. What are some of the implementations that you were able to guide you through this?
G: Yeah, so, you know, I'll have to give some kudos here to two groups. First of all, HCA Healthcare, who's funded the whole thing, but also that we now have a physician wellness research lab, which is outta Claremont. There's five doctoral students there under Dr. Jason Siegel, who's a full professor there in the organizational psychology division. And so they're the folks that really help us with these implementations. Like what are the tactics that are involved. And they study this, you know, pretty much full-time now for us, and we'll certainly share those as we learn them.
You know, in terms of those three: autonomy, belonging and competence. The one that's probably the most important is autonomy. And that's why, you know, the leadership style that helps support self-determination theory is called autonomy supportive leadership. Sometimes you'll hear it called needs supportive leadership, which, you know, it recognizes the other two. But autonomy is probably the biggest issue because it's so important in what motivates people. And if you can get people to have enough autonomy and then some degree of belongingness, and competence, they just generally flourish. So autonomy is where I would start with, and some of that with the C-suite level really goes again to what we just talked about with beliefs.
So you know when you're sitting around a table and you've got multiple people, like CEO, CFO, COO, Chief Nursing Officer, HR, Legal, potentially Marketing, but whoever, and they're all chiming in on things like policies. There usually isn't somebody in the Chief Wellness role or whoever that Champion is who is able to use language that everybody understands and says something like, “Hey folks, you know this policy you're saying. I get everybody saying it's great, but it's going to undermine autonomy, or it's gonna undermine competence. And you can choose to do that, but do it deliberately and recognize its impact on the physician well-being. So that later when you look at engagement surveys and you say, ‘what happened to our engagement?’ Well, I can tell you what happened. It, you know, you did a policy that thwarted autonomy.” And so I think that's, you know, just in terms of, again, that culture of understanding beliefs and values is really important. But having that toolbox, as you guys even mentioned before, that that sense of understanding those three simple things, and just keeping those in mind whenever you're talking about policies, procedures, and just the direction that the institution is moving in.
I'll talk a little bit , if you're okay with it, with the way we do autonomy in graduate medical education. And that's a really specific thing, although I will say, it's certainly reasonable to use in all settings. Partly because everybody's a leader, in some ways. It varies, but especially autonomy, is quite important in graduate medical education. And so when you think what autonomy is- I'll mention here or something cuz it's important- autonomy doesn't mean you get to do whatever you want to do. That is a mistake. And sometimes I'll hear people say, “well that's crazy. You know, I'm not gonna support autonomy because we can't have docs running around doing whatever they want to do. You know, that's what we used to do before the quality initiatives kicked in.” Right? So what we're really talking about when people say autonomy is a sense of ownership in what one does in their life. So the sense that what I do, I choose to do it because it's in alignment with my own values and that I understand why it is I'm doing these things and it aligns with things that I care about.
And so essentially psychologists would like to use the word agency, which just means I’m doing things because I'm choosing to. And the contradistinction of that is really the people who feel like they're just being compelled or coerced, right? And that's where you thwart autonomy. There's lots of ways you can compel or coerce people to do things. So learning how to see where there's opportunities in the work and learning environment as a leader to either support or thwart autonomy is probably the most important thing. So just knowing, being aware of it. And thinking at that right moment, “Hey, here's a moment where I'm gonna support autonomy.” And in graduate medical education that comes up all the time. And the example I typically give is that, you know, imagine a brand new physician just graduated from medical school, has an MD or DO after their name, and they come up to me in the emergency department and say, “Hey, I'm taking care of this guy with a wrist fracture. Should I give him four milligrams of morphine or six?” Now that's an opportunity right there to, if you understand self-determination theory, that's a beautiful opening to decide, “am I gonna support or thwart this?” And classically, in medicine, we typically would say something like, “give 'em six.” And that's somewhat the arrogance of physicians, you know? Right. Just, just tell 'em what you believe, and that person will dutifully go off and give them six milligrams of morphine. But it completely just took away the ability for that individual to either understand or make their own choices.
So if instead of that someone were to say something like, “well, what would you like to do?” And I'm being very careful with the wording, so what would you like to do? And this assumes by the way that I don't care whether it's four or six, if they said, “do I give 'em four or twenty?” I very much care, but four or six, all of us in medicine recognize, you know, that's just, I'll give him enough medicine to make him pain free. So four or six doesn't matter to me. So I may say to that resident, “well, why don't you go ahead and decide? Why don't you decide?” And they'll say, “six milligrams.” “Great if that's what you wanna do.” So note the wording again. If that's what you wanna do, let's give 'em six. Now that little moment, I think all of you can really appreciate, in that brand new resident walking away from the attending with that moment of what do you wanna do? Well, I wanna do six. Well if you wanna do six, let's do six. Suddenly has a sense of agency, and they walk away feeling like I'm a real physician now, as opposed to just give 'em six. And we call that flexibility, which is recognizing when there's options and not immediately jumping in with one's own thoughts and ego. So very frequently, for instance, I'll have a resident ask me if I need a chest x-ray. And I don't care, and maybe I will, my partner might not. I don't know. You know, if it takes me more than a few seconds to think about it, that tells me it's an opportunity to support autonomy. And at that point, just to say you've been training a third year, for instance, “you've been training long enough, why don't you decide?” And I still may ultimately decide I want one later, as an attending, but just giving that autonomy is again, deliberately supporting autonomy. And so when you can be flexible, we're really fixed on being flexible.
Now there are times where you can't. Again, I can't let people run around and do whatever they want. So if I can't do it, then again, I can either just tell people what to do and that's thwarting their autonomy. And I will say that's ubiquitous in graduate medical education. It used to be called scut, right? It's scut work because it's meaningless, and someone just told me to do it. I don't have any intrinsic motivation to do it, typically, I'm just doing it. Ask any prelim surgery resident, right? What that's like. And so, your opposite of just telling people what to do, if you have someone who presents something that's not gonna work for you, is trying to, again, align them with their values. And so a good example for instance, would be a resident who presents a patient with syncope, you know, fainting episode, and they wanna admit the patient. And I've already seen the patient, and I've talked to 'em, and I don't think they need to be admitted. So I've got a couple options there. And this is again, where you have to be mindful enough- that's where coaching can come in, I suppose. Be mindful enough to stop and recognize this little opportunity to be either supportive or to thwart autonomy. And so, in that moment where the resident wants to do something that I’m not gonna do, I can either say something as quick and glib, as you know, “Don't do that. Just get another troponin and send him home if it's negative.” And then walk away, and the resident will dutifully do that.
But what you've done in that moment is thwarted their autonomy and dropped their workplace engagement a little bit. So instead, one of the things I can do is say something just as simple as, “well, do you know of any guidelines or ways of helping determine who can be safely discharged home with an episode of passing out?” And they might say, “the Canadian Syncope score.” “Great. Why don't you go read that for 60 seconds, come back and tell me what you wanna do.” Now again, notice the wording. I didn't say, tell me what it says, tell me what you wanna do. So they come back and say, “well, the syncope score is low, and it looks like they're low risk.” So again, “what do you wanna do?” “Well, I think I wanna send him home.” “Okay. If you wanna send him home, I agree with you.” There's my supervision. You know, “I agree with you. Why don't we send him home?” So notice all of that wording that's very focused on that sense of what do you want to do? And it leaves that individual feeling as though they have had agency. That's been their decision, as opposed to, I just told them not to.
So, that second one's just called nudging. So with flexibility and nudging, you begin this idea of supporting autonomy. And that's just one of the things that we teach a lot of our faculty about. Just to be aware of those little moments where you can support it that way.
A: I think it's interesting that you bring up that autonomy is probably the most important thing because that honestly was the source of my biggest frustration, even outside of residency training in my career. I would get involved with a committee, think that we'd have a great idea, and then somewhere in the upper echelon of the hospital leadership, it would get squashed. And it only took a couple times. You referred to Marty Seligman, which our coach training, by the way, is heavily into positive psychology. But when somebody finally told me about learned helplessness a year or two ago, that's exactly what I had experienced. I had tried a couple times. It got squashed. So I just stopped trying. I learned that nothing that I did mattered. And that took away, I mean, I went into medicine to change the world, right? I wanted to do things. I wanted to help people. And that being taken away, even though, you know, a lot of it was in my mind, it was devastating to me. So I love everything that you're saying.
G: So I agree with you that especially when decisions are made without your understanding of what occurs, and why those decisions are made. So again, I mentioned earlier that autonomy just means that I'm going to go along with the plan because it aligns with my values. And so frequently if we actually understood what was going on underneath it, a lot of times that does align with our values. So, you know, I think all of us have, in emergency medicine, know the whole sepsis bundle and all of that. And, I'm old enough to recognize when we put central lines in everybody who had fever essentially, back in the early two thousands. And I think it drives everybody a little bit nuts because the autonomy.
But one of the things that has helped, for instance with us, is just pointing out, for instance, to the residents that our really septic patients have a higher, far more elevated mortality than the heart attack patients and almost all traumas with the exception of gunshot wounds. So you're talking about 35% mortality. And so, here again in terms of autonomy, when the residents are like, why do we have to do these protocols? Well, part of it is because people are dying, and I know you don't see them as an emergency physician because they die upstairs in a day or two. But you need to recognize that this person in front of you, who's a human being, who you care about, why you went into medicine, is really in trouble.
And so that's why we use these kind of protocols. So if you can give some of the background, sometimes, these decisions, in ways that align, understanding now sometimes you don't agree, right? And you're just gonna have to say, “Now I have a decision to make. Do I try to buck this and, you know, plant the flag on the hill, and go to town on it? Or do I let it go?” And what I will say is it doesn't have to be a hundred percent. You don't have to have everything happening in the ER or the organization to be autonomy supportive, but you need some percent. In self-determination theory, they often talk about quality over quantity, and so there really is the some threshold. I don't know what it, but certainly if decisions are being made that you don't understand that are affecting the physicians, that the leadership needs to understand a little better how to make sure those decisions are put out with input from the physicians, ideally, or at the very least, some transparency as to why they're occurring. And sometimes those are, you know, those reasons might not be ones you like.
A: Yeah, I think transparency would go a long way in helping understanding and that feeling of, “you're not just telling me no because you just feel like squashing my hopes and dreams.”
G: Well, there are malignant individuals, but that's uncommon. I don't think most people in the leaderships of most hospitals, you know, are out to get people. I meet a lot of leaders. I was in 10 hospitals last week, and I will say everybody wants to help. They just don't know what to do, you know. It's genuine and well intended to put massage chairs in and all of that kind of stuff. They're, they really are trying, I think.
K: Yep. I love how when you had mentioned, you know, what true autonomy is. It's not a hundred percent. We don't have to go all the way and expect administration, organizations, institutions to go all the way. It is just some sort of balance. And I love how the belonging and the competency also plays a role in that. Because I think that would also kind of bolster or maybe encourage the- not work engagement, but the, what was the other term?
G: Workplace engagement. That's vigor, dedication, and absorption are the three groupings of that.
K: And so, that to me seems like, “this may not be, you know, as hard, as hard as it seems or as big of a battle as it seems sometimes.” And so that's also reassuring. But you also mentioned something that kind of goes with the ABCs and that was the meaning. So, what kinds of things have you done or have you been a part of that promote that meaning back into our work? Cuz we all want to feel that what we do is meaningful.
G: Yeah. In self-determination theory, if you have autonomy, belonging and competence, you typically develop meaning out of it. And so, you can get meaning just with those three. But we have gone a lot farther in recognizing that medicine. We're quite lucky to be in a specialty that from an organizational psychology standpoint, It's just dripping with meaning. I mean, there's so much meaning involved in what we do. Compared to if you're an organizational psychologist working with lawyers or businesses, sometimes it's a lot harder to recognize pro-social meaning, but we have it everywhere.
What I will say is, though, that you need two things. You need to be deliberate and you need to pay attention. And, you know, I like to show the Chabris and Simons experiment where they have the gorilla in the background. You've probably seen this one. You motivate people by telling them that only the smartest people can count it correctly. And then you show the video of people passing a basketball between individuals, and you're supposed to count the number of times it's passed. In the middle of it, there's a gorilla in a full size gorilla suit comes out, clumps its chest, and walks off the stage. And it's truly remarkable that, in the initial studies, it was 60% or so didn't recognize the gorilla at all. In fact, they were pretty adamant there was certainly no gorilla in the room. And then when you replay it, it is just stunning to watch people. And I like to show that as a really good example that the idea that your brain takes in everything as if it's real. In other words, there's a reality out there and your brain is just one-to-one connected to it is very incorrect. We very much control and filter what we pay attention to, and that's one of the great examples.
And so if you don't actually filter yourself to pay attention to meaning, then you're going to miss it. And so, what we're talking about is being very deliberate. And so we started from the beginning with a very deliberate approach to: how do we magnify, how do we recognize, amplify, and then reflect back meaning? And so here's two ways that- I'll just give you some, a couple quick ways to do this. That one of the things we do, for example, and you can do this even if you're not in a teaching hospital, because you've got lots of people around you, nurses, RTs, techs and paramedics and everybody. But when you finish doing something, say an intubation on a resuscitation. For example, we have a resident, and she's up at the front of the bed. And we have a complex resuscitation. And you know, she's able to get an airway that's really difficult. One of the things that we do is the faculty will deliberately point out (A) the competence. So they'll say, “wow, that was a really difficult airway. Think back when you were, you know, PGY one and your, your very first airway, and how much you've grown between those two times.” And so that's a deliberate effort to bring to attention again, just like the gorilla, the fact that the competence is there, right? That you've grown. And I think we do that okay in medicine. What we don't do though, is the next step, which is to (B) notice the prosocial meaning of what just happened. So beyond just saying, “Hey, good job, you've really grown.” But to be able to say, “do you recognize your role in saving this person's life? I mean, Mr. Jones here, who was in a car accident, has a real risk of dying. And your role in this, in putting that airway in, may well have saved their life. So I want you to take a moment and let that sink in.”
And I'm pretty deliberate about saying, “take a moment, let that sink in.” People don't, you're emergency physicians, you walk off and you're doing other stuff. But I hope to open up the brain a little bit, the mind a little bit, to letting that sink in. And so we do that at the bedside fairly frequently. Again, there's some threshold, I don't know what it is, but enough. It's not every single patient, but being very deliberate. Because again, we all recognize the belief structure is important, Autonomy, belonging, competence, meaning. And so we value that social practice of pointing out competence and meaning.
Now we also do something called What Went Well. And it's probably one of the more important things we've done right from the beginning. This was a positive psychology practice that the organizational psychologist taught us right before. Before we had any residents, actually, we did this. And so before every one of our didactics, we have a formal What Went Well. And we literally just say, “okay, let's do our What Went Well.” And individuals in the group will just kind of say something that went well for them, either in their professional life, their residency, or potentially just their personal life over the last week. And we teach our residents and our faculty how to respond to that.
So we actually teach something called active positive responding, or active constructive responding. So we teach how do you respond to a team member who makes a bid for attention? So when somebody says, “Hey, I got my first lumbar puncture on a baby this week.” How you respond to that as a group is actually quite important. And anyone who's had a long-term relationship recognizes how people respond to a bid, you know, has profound impact. So if you stare down at your phone and say, “well, that's interesting,” and walk off, that's a very negative thing. Or worse, you say something like, “wow, it took you that long to get a lumbar puncture. I had it my first week.” And that creates a spiraling emotional state in the group. And so we're very aware of emotional contagion, and so we train people how to react to that, first of all.
Then the other thing that we do, of course, is that's an opportunity to do exactly what we just talked about at the bedside. So somebody says, “Hey, I floated my first transvenous pacemaker this week.” Everybody's, “wow, that's fantastic. Tell us about the case.” There's a lot of active positive response, and then someone in the faculty or the chief residents do it now too. We'll say something like, “Hey, don't forget. That back when you first saw the procedure, there was no possible way you could do it. It was extremely complicated. Now you've grown to the point where you've done that. And also remember, that Mrs. Smith, who came in with a heart rate of nine was on death's door and is now upstairs in the CCU waiting for her pacemaker with her family at the bedside and not dead. And that's because of what you did. Take a few seconds and let that sink in.” And so we use the What Went Well to develop belonging through active positive responding and just the general emotional contagion. We use it to push competence as well because , it's bringing to attention, that deliberateness of attention, to competence. And then we again, bring deliberate attention to the pro-social meaning. And so we used that What Went Well to [bolster] both autonomy, belonging, competence and meaning. And then also the psychological capital, right? So it develops hope, self-efficacy, resilience and optimism through a practice as opposed to a, you know, online module or course or something you have to take as part of your wellness curriculum or something. And so those, kind of, are some of our just basic kind of practices we use.
A: I love that so much. And this has so many implications. I feel like when the only feedback you're getting is angry patient, you know, complaints, or your Press Ganey scores are too low, or you need to, you haven't satisfied this metric or something, that can kind of erode the competency. And the other thing that I am taking from this is I'm gonna be a lot more deliberate about pointing out to the nurses, to the paramedics, the housekeeping services. They're part of the team. Because I know this. I just feel like it, but I probably take it for granted that they know this too. And so I do love this. So here's the next question, though. Let's say that you work at, probably the majority of listeners work at a facility that already has a culture in place, and isn't being built from the ground up. So what sort of advice would you have for somebody trying to change an institution who's, you know, a little in the crunchy stage?
G: The institutions in the crunchy stage. Yeah. You know, everyone's heard , the Gandhi quote about be the change you wanna see. I think, you know, you, you really have to start first by taking responsibility for your role in developing autonomy, belonging, competence and meaning. And people notice it. So one of the things I get asked a lot is, you know, “what do you do for faculty development?” Well, we do the same thing. Because the faculty are no different than the residents. The faculty thrive on autonomy, belonging, competence and meaning. So as the faculty are in their own head thinking through, “don't forget, I have to make sure to push competence and meaning and belongingness,” they actually get that same exact benefit right back to them. So even just for yourself, when you're in those institutions that maybe aren't yet aligned in terms of belief and value in social practices, starting yourself. And I absolutely love, Amanda, your comment of the housekeeping, for instance. I try to tell residents, you know. Physicians, I realize we've had an erosion in some ways of respect in the environment, especially with Covid, but still, the vast majority of people have a fairly high respect for physicians. And so if you walk up to someone who's cleaning a trauma room after you finish that resuscitation and first say, “Hey, what's your name?” Because that, that creates a narrative of I matter. And then to say something like, “we can't do what we do here without you cleaning these rooms. What you do is so important because it allows us to do the things we need to do to save lives. And this is a chain, and your role in this is helping us to save lives. So thank you for what you're doing.” I guarantee that person went home and told their family that. There's no question in my mind that happened.
And it's such a simple thing that by the way, costs nothing. I'll point that out. Cost, you know, 20 seconds of your time. So (A) be the change that you wanna see because you will begin that movement. I do think ideally, if you get your C-suite or whoever makes the decisions in your institution to begin working on the belief structures. That's really one of the things I'm working on right now with our institutions, all of ours across the US, is we have to first get people to buy into this concept. And that's why we did the nine waves of research. We're hoping to have pretty profound evidence that this is helpful. And by the way, this isn't, you know, I can make your environment pretty optimistic if I have enough money, right? So I can just dump a ton of money into things, and everybody's happy. But nobody has a lot of money in medicine anymore. That's just not happening. So we have to focus on things that are actually realistic including for places like the county hospitals and the safety net hospitals that really struggle with their revenue.
And so going to the C-suite and talking a little bit about these concepts and just generally trying to socialize. So if you're the wellbeing champion at an institution, and you have any sort of sway, beginning the idea. Be deliberate with this, you know. There's beliefs you have to get across. There's values you have to get across, and there's some social practices. So if you started What Went Well at shift change or huddle for instance, which there's a little bit of research on that. I've been involved. That's that same idea, and you'll start getting people feeling good about it.
Now it has to continue. There's entropy, right? Entropy will just- you guys are coaches- you get this. So someone will say, “that's a brilliant idea. I'm gonna do that in my life.” And they do it for a week and then six months later they haven't done it. And that’s just entropy, and so you have to be pretty deliberate again about making sure that the things that you begin to start within your institution continue. But it's not an easy task for sure when there's other pressure.
W: So if we have any wellness officers or c-suite people that do have some sway, are there resources that you can refer them to or some way that they can get in touch with you or somebody else? How would they start?
G: Sure. Yeah, I can share with you my email or however you want to do that. That's, I don't mind. I generally can't spend a lot of time getting involved myself, of course, with other institutions. There are a couple of different articles out there that I'm happy to, you know, I don't know how you wanna do it, but I can share those with you that are just good background articles on the concepts. We are working on a project right now. Again, my focus is with graduate medical education in my role. And so we're working on a project right now of a bunch of videos, for instance, to deliberately show the faculty what thwarting looks like versus supporting each of those needs in different types of specialties.
So, you know, the old surgical M and M. I don't mean to bash surgeons, but surgical M and M is just about as opposite of supportive of autonomy, belonging and competence and meaning as you can get. And they're moving away from it. I will say the American College of Surgeons has done a really good pivot on their wellness front, and there's still other people that maybe are different generations still believe that the way you build wellbeing is to create resilience through intentional adversity. And those folks are not gonna buy into this, but you know, a lot of surgeons have done quite well with this, I will say.
A: Yeah. Well, I mean, if we're going to the ABCs, the way that it had been done in the past is in direct opposition to the feeling of competency. And pimping rounds. I don't know what they call 'em anymore, but that's what they called them back when I was in the…
G: Well, and you know, you, you can certainly do- they called him that too when I was in medical school- you can certainly do pimping and still support autonomy, belonging and competence. So there's a saying that Rich Ryan said to me because after a discussion I had with some faculty, at one point someone said, “you're just asking us to be nice to everybody.” And it's like absolutely not. Rich Ryan was like, “you can be really mean actually, and still support autonomy, belonging and competence. That actually is possible.” So it's not really all that much about being soft on people. You can actually have very high standards and demand very high results.
My experience in the military. There's some leaders that are phenomenal. I don't have any sense that they're loving me as an individual, and wanting me to, you know, necessarily, on a personal level, succeed. But they certainly support autonomy, belonging, and competence through the ways they interact. That's a little trickier to do, to be mean and still support autonomy, belonging, and competence. But, it is possible. So it's really not about just being nice to everybody. It's a different concept.
A: Yeah. I'll be honest, I want all my doctors to be at the top of their game. I don’t want that, but I don't know that it is accomplished in certain situations. But I would love to attach, we'll- on our show notes, we'll attach all of those resources that you think would be a good starting place. And we can just attach links there. But thank you so much for coming. Do you have any closing thoughts that you'd like for the listeners out there?
G: Well, I think there's several things. And perhaps some other time we can talk about things like help-seeking behaviors of physicians, which, for instance, that's one of our big topics. We've done quite a bit of research on this. And we recognize that, for instance, residents. The more distressed residents are, in terms of depression, the less likely they are to ask for help. And that is a real problem when most organizations move to opt-in type of help environments. Where they say, “look, if you need help, here's how you do it.” Well. The most distressed people won't ask for help. And so, I would say, you know, whatever you folks in the coaching world can do to lower stigma. Stigma really is something organizations need to work on. But you can help a little bit with individual approaches to mental health and help seeking. Once individuals actually make first contact, they tend to do better after that. And so, you know, that's one of the things that we've done some work on in terms of research on opt-out versus opt-in therapy sessions. So, as coaches, do what you can to try to remove that stigma. It's pretty important.
A: That's kind of our thing is that we're not mental health professionals. This isn't in an electronic medical record somewhere. You're talking physician-to-physician. So I've been there too. I know exactly what you're talking about when you're worried that somebody might have died because you missed something. But then also I'll send you an article that this year in 2022, the University of Colorado published their group coaching practices for residents, and they showed good engagement, and all the things. So I'll reciprocate and give you some articles too if you have any use for those, but thank you again.
G: You're welcome.
L: Yes. Thank you so much.
K: Thank you, Dr. Guldner. We have been just amazed by the availability of the information that you've put out there. It's very relevant, but you just make it even more available. Because it's so applicable not only to our colleagues, but to our institutions. I mean, to our families, to the relationships that we have beyond the emergency department. You know, I am a medical director at our shop, and I have taken away so many things that even coming forward soon in a meeting tomorrow that was like, “wow, what is one thing that I could do to even just reciprocate that autonomous feeling or that feeling of meaning or that feeling of belonging or competency” just in that meeting tomorrow. One thing.
Thank you very much for inspiring all of us to even just do the one thing- talk to the EVS people at the end of a trauma or thanking the registration people for getting everyone back to the rooms or checked in correctly. That's a huge part of throughput, so everyone has a part. And thank you for helping us to just see it and be so accessible.
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