Health Care Workers: Navigating Challenging Cases

adverse events first trimester fourth trimester provider care provider support second trimester third trimester Aug 14, 2023

Bad things happen in medicine. Sometimes it can't be avoided, but what we can do is try to prepare ourselves the best we can. On today's episode, Dr. Alicia Power & Dr. Maryna Mammoliti discuss what we can do in such events, the concept of radical acceptance, and how we can plan both as individuals and organizations to support each other during such times. In conjunction, we have created an Adverse Events Plan Template to help you build a tailored framework for moving forward.



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[00:00:00] Dr. Alicia Power: Hey, it's Dr. Alicia power. Welcome to the Pregnancy for Providers Podcast. Today, we're talking with Dr. Maryna Mammoliti and we are talking about how had things happen in healthcare. And this conversation, frankly, took a bit of a turn I wasn't expecting. And we had a wonderful discussion around radical acceptance. And what that means in terms of healthcare that we all go into this business to help people, however bad things are going to happen. And that is just something, unfortunately that we need to accept, but accepting that we can also do some things to prepare for it. So one of the things she actually recommends is we do a preemptive self care plan and adverse event, self care plan, which means we think about the worst case scenario and what we would need to do as individuals.

[00:00:47] To help move forward. After that scenario and create a plan. So what we've actually done is come up with a template. So that you can download. And if you're interested, do this yourself, or bring together a group of your colleagues. [00:01:00] Or your department to do it all together. So whatever feels good to you, but we've created a download. So check it out at pregnancy for professionals forward slash care plan.

[00:01:10] And download it and work through it on your own, and then feel free to share it with a colleague with your partner, with whoever you think might need to, or just put it somewhere safe. So if something bad or when something bad happens, you can refer to it yourself.

[00:02:13] Dr. Alicia Power: Welcome everybody. I have the pleasure of talking today with Dr. Marina. Memmoli. who's a psychiatrist in Toronto. And today we're going to be talking about. How we as healthcare providers can help to recognize and create a plan around potential bad cases happening because we all know that they're going to happen. So how can we think about that? Reframe it in our minds and also prepare for that eventuality. Marina, why don't we start off by you telling us a little bit about yourself and how you've come to do the work that you do.

[00:02:43] Dr. Maryna Mammoliti: Okay. Hi everybody. My name is Dr. Maryna Mammoliti, I'm a psychiatrist in in Ontario as Dr. Alicia mentioned. I am a bit of a night own, so it's a bit early morning for me here, uh, what I do is I do a lot of psychiatric care, general psychiatric care, psychotherapy, and I [00:03:00] do some executive and boundaries coaching as well. And majority of my patients over the years, I've been physicians as well as dentists and lawyers and other high stress jobs. First responders. And as we know that these, professions are high-risk, know, as physicians where our mental health is at much higher risk. we struggle with a lot of trauma and other things. And so the first responders and lawyers, if you'd be surprised and dentist. In any case.

[00:03:27] So I do a lot of physician health work. I have treated physicians since I started my private practice, for years now, since 2016. And not only do I work in psychotherapy on people that struggle with, but also, wellness, how to maintain wellness, how to continue practicing medicine without necessarily having to carry the vicarious trauma and the burnout, right? And so I work with a variety of physicians in therapy, to work after difficult events, including a difficult patient events, but also lawsuits and and things like that. As well, as, you know, in general, [00:04:00] kind of helping them create a career that they want to be in.

[00:04:03] Bad things happen in every specialty, right? Like, bad things happen in medicine. So the way I talk is a general way to explain, to helping people to accept as a concept called radical acceptance. So radical acceptance is a concept that comes from dialectical behavioral therapy. And dialectical behavioral therapy is a therapy that was invented by Marsha Linehan. It's one of my favorite therapy modalities and Marsha Linehan is an American psychologist who invented this therapy for people with borderline personality disorder. And as we know, borderline personality disorder in itself, it's quite complicated condition and carries about 10%. you know, one in 10 people will die from it. So this is a pretty, pretty good therapy for a pretty complicated condition, right? But a lot of the principles into DBT are applicable to other conditions, and in life.

[00:04:54] And so radical acceptance is part of those concepts in this therapy that is applicable [00:05:00] in every aspect of our life. And what radical acceptance says is basically, we have to accept that life is going to have bad things. Life is full of pain. Life is full of disappointment. And it's really the distress in our mental struggle comes from, you know, our failure to accept that life is going to have bad things happening and if you really think about it, that is what we get stuck when the most is the why things are happening. And a lot of us have got a illusion that life is going to be either happy or stress-free or, you know, practice. As you know, residents as we go into practice we think, you you know, you have this kind of illusion that our practice is going to be somehow good or different than our residency. Or stress free or we're going to have a control or it's going to be fine. Or, like our medical practice can be fine without complicated cases without any badness. And that is [00:06:00] a false fantasy. Okay.

[00:06:02] That that is what it is a fantasy. That's not reality. Reality is, we're going to be disappointed. We're going to deal with difficult cases, pain, loss, death complications. And, you know, sometimes people say I've never been prepared for a case like this. Of course, you're not going to be prepared. Our brain, our imagination cannot possibly imagine all sorts of badness that can happen. Because we don't sit there and think about all sorts of permutations of badness that we can encounter, because it's just not possible. Our brain cannot imagine that, especially if you're not a psychopath, you know, thinking about all sorts of ways that somebody is going to get harmed.

[00:06:41] So it's totally normal that you might not imagine all the potential badness we will experience in life or in professional, you know, experience because it's just not possible. But we do have to accept the fact that badness will happen. But that is radical acceptance. If we [00:07:00] choose to practice medicine, we have to accept that we're going to have college complaints. We're going to have sad cases we're going to encounter. We're going to see things the general public is not exposed to, because again, it's not going to be necessarily on the news. It's not going to be talked about. And luckily it's not the experience of the general public to experience the badness that we might be exposed, in a role as whatever physician we're playing to that individual, whether it's an obstetrician, psychiatrist, emergency doctor. So that is step one, is to truly accept that badness is part of our work. Badness as part of life. It doesn't mean that we engage in this helplessness, "well, life sucks." No, no, that's not radical acceptance.

[00:07:43] Radical acceptance is we just accept that bad things will happen. And what would choose about it? That's the part two, right? And that is really the concept of dialectical behavior therapy is opposites are true at the same time, [00:08:00] dialectics, right? And it focuses on acceptance and change. And what are we going to change?

[00:08:07] You know, life is hard. Medicine is hard. OB is very complicated in the context of actual medical, but also the interpersonal context of what you're dealing with. And what do you choose to do about that? And that is where people get stuck. That is where people get stuck over and, oh my God, no something bad is happening. What not. And when we're looking at choises, what do we choose to do about it? Right. That's really helped to look at our own personal choices, if something bad happens, what do I choose to do about it in terms of do I just dial my own therapist where it's confidential and some skills and you know, somebody can objectively, confidentially support me. Do I choose to have a peer that I trust, you know, I could talk, potentially discuss with. Do I choose to have my own [00:09:00] set of activities that I know could be very helpful for me to go through a difficult time. Do I choose to potentially focus my practice area on the practice area that is less triggering for me or more, rewarding for me or fulfilling. There's my personal choice. What do I choose to do within the system? Or would they expect from the system, you know, but then actually, you know, what might be time to give up after a difficult case for the OB or the resident or med student, even just take that time because know, we all react to things differently.

[00:09:31] It has to be individual, not everybody finds the same event traumatizing, you know, some people might have a very different view on it. Do I choose to have something else in the system? And again, are they events because you know, this is just the nature of the disease or complication. Or was there negligence that added to that, right? Because that in itself makes things very different. If, you know, you encounter a bad OB case because that's just the nature of labor that was just not [00:10:00] progressing or the nature of the condition that right. that the infant was born with, because that's just the nature of the, of nature. Things happen. Badness happens in nature.

[00:10:10] Or is it things were missed or was it a systemic issue that somebody who didn't have access to medical care to prevent this. Or was it you know, the patient didn't have the understand and your insight into the seriousness of this condition, right? Or is that we didn't have access to imaging and whatever other issues that prevented us from realizing how bad the condition was. You know, and I'm thinking, when we have people coming in from remote areas you know, people who live in Northern under service areas, at least in Ontario. You know, they often face real systemic barriers to getting good care that could result in devastating, uh, impact on them and on their bodies their babies, right? So again, that's where we have to look. We have to accept that badness is going to be. And do we change our expectations in our behavior? Do we [00:11:00] change the system and look within the system. And that is my biggest single piece of advice to anybody in medicine. Is to accept that, we are going to have bad things, in life. You know, same thing I tell my children, you are going to be disappointed. You are going to help people who are not going to be nice to you. You're going to have people who are going to betray your trust to refresh. That is not a shock. That is the reality. And when that happens, what options do you have or what do you want to do? Sometimes you might be able to prepare. And other times what you prepare is knowing who your supports are, knowing that the options are. knowing that you might.

[00:11:49] Be able to create that space, to just think about your options because that in itself, right in medicine, we have to not have the space, like literally the time to sit there and [00:12:00] reflect and say. What do I actually mean? And if you think about obstetricians and any physician, there's just, we have so much time demand, right? If you're on call as an obstetrician, and something goes bad, or if you're the resident. Barely anybody says, okay, you know, this just went really bad and there's a mortality and take your time or go home or? Okay. Go hang out for a couple hours and let us know then what you need.

[00:12:30] And to me that is step number one is actually asking the person. What do you need? Do you need to go home and think about it. Do you need a couple of hours in your call over. Do you need a couple of days? And get in other areas, right? In medicine, people have access to that, or even other jobs. Even nurses will have a very different, you know, ability to potentially take a couple of shifts off or call in sick. As physicians, we don't [00:13:00] have that.

[00:13:01] Dr. Alicia Power: No, we don't.

[00:13:02] Dr. Maryna Mammoliti: And even when I have learners, medical students or residents, sometimes, what we really have to do is is to say, listen, this happened. I'd like you to have some time, you know, either go to the call room and take that time to process this and come back whenever you're ready. Or would it be better that you go home? You know, we also don't want to push them because maybe they don't want to be alone with this intense emotion. Maybe they don't want to feel punished that you're sending them home. Right. Because again, the called the resident interprets you send him home is very different. So that's what I'm saying, you know? We can't really make a blanket uniform policies because people might be very different. I've had medical students who are paramedics previously, them, know a paramedic who's now a medical student or resident is going to deal with a death very differently than a medical student or resident who has never experienced this or has a personal experience of [00:14:00] deaths, or potentially pregnancy or pregnancy loss.

[00:14:02] We can't assume that everybody is going to react to badness the same or how we will. Because everybody has a different background. Everybody has different personal, professional, mental health background. And we really have to respect for them, but to do that, we have to give them the option non-judgmentally, non shamefully to say, listen, respecting your needs. What do you need? And again, I've had to do that with residents when we had complicated cases or, you know, bad things happen on-call and I have to respect it. Sometimes some people want to take a couple hours in the call room, but to come back because they don't want to be stuck with this thoughts and feelings in the middle of the night, by themselves, in their home. [00:15:00] work. and the self could be distraction until the next day.

[00:15:05] And then they can reach out if they have existing supports or other things, right? So that is my thing. Number one is radical acceptance. Badness is going to happen. Disappointment is going to happen. As OBS you are going to have bad events. People dying, babies dying, mom's dying. It's just the reality. We hope that we don't encounter that reality very often. But that is just the reality. No different than every time when I get into the car. I have to accept the reality that I might get into a car accident and die. It happens every single day, people die. You hear on the news you know, fatal car crash, collision.

[00:15:50] Most of us. Don't think of it, but that is literally the risk we have to accept when we get into the car. And many of us try to do [00:16:00] things to reduce the chance, maintaining your cars, driving safely, not driving impaired, driving the speed limit. We can't control the weather. We can't control random, various severe failures in the car even if you maintain it. We can't control other people's behavior on the road.

[00:16:20] And that is like medicine. We can control our preparedness and maintaining your skill level. We can control our alertness, right? Making sure that we're well rested and that we are alert. We can make sure you're not impaired by substances. Again, ensure that we provided, you know, the treatment we think is best up to our clinical knowledge based on the information available. Which might not always be available, right? We don't always have the information. And cooperation from the patient, because again, the patient might not understand what we know the patient may not have insight. The patient might not understand the language, the health information might be too complex. So we have to accept that you do your best. [00:17:00] And things you can control. And with every shift you choose to be a doctor, there's always a risk of badness. What do you do when badness happens? And that is very individual to each person. Because one person finds helpful, might be extremely agitating to another person. Where you traumatized? Frustrated? Even things like when we talk about breathing again, some people might find it violating. Some people might find it helpful. Some people might find it frustrating, and with the debriefing too, again, if it's enforced, anything that is forced might be just another way of feeling was just a systemic check. It's not really true.

[00:17:49] And if somebody has like a past experience, let's say they have their own personal experience of a traumatic birth or, they had [00:18:00] miscarriages or they lost their pregnancy. Again, the debriefing, the forced debriefing could be very difficult, it might re- trigger and bring in way more stuff than even the general person who's doing the briefing can handle. And you don't want to open up people either. We don't want to open up people and then just leave them hanging. '

[00:18:19] You know, that is sometimes one of the biggest issues is that, when people are so raw and they mentioned something and they see that the person who has been debriefing is overwhelmed, you know, and that frustrates them too. So there's just so much sensitivity about the right support for the right person at the right time.

[00:18:41] Dr. Alicia Power: How do you counsel people or how do you support physicians, residents, med students, any healthcare providers in figuring out what is going to be beneficial? Because like you said, we all know that bad things are gonna happen. Some of us more than others are kind of planners and would love to be able to prepare for those [00:19:00] bad things in terms of understanding what might be helpful for us? Do you have is there a way that you counsel people or recommend to people to do that? Or is it one of those things that it's in the moment you just look inward and try to figure it out.

[00:19:14] Dr. Maryna Mammoliti: No. So this is awesome. So I'm going to equate this to kind of like what we talk about with our patients with suicidal thoughts and crisis plans. Again, we're going to accept that patients are going to have suicidal thoughts. We can't avoid them. What do you do when you have the suicidal thoughts? Ideally, you have a crisis plan and you write down the different steps at which point do call a friend. Do you use your soothing strategies? Do you go to the emergency department or do you call them a lot? Because you know, people are having different stages or where they can do things before they need to come to the emergency department. So ideally we would have this discussion with residents, with staff. Preemptively, ideally again, we would start from the point of radical acceptance to say, you know, whether it's your, [00:20:00] you know, your lecture number one, when you're welcoming your residents or medical students, or when you have your new staff joining, where you as a department sitting down and looking at: what is your crisis plan? Just like when we do with somebody who has suicidal thoughts, right? And and then everybody could do their own crisis plan. Or their own badness plan. Or they're own whatever plan you want to call it, adverse events plan.

[00:20:26] And again, because we want to plan it when you're not in crisis. You know, again, you want to plan it when you're not in a car accident. You want to make sure you know where your things are, if your car's broken down or where you're next and you don't want to be scrambling when your car's broken down the middle of nowhere, not knowing what your equipment is or batteries or blanket. So ideally you do it preemptively. And preemptively each person, again a good, either share the crisis plan with whoever might be appointed in your department as the wellness lead, you know, that [00:21:00] identified kind of support person. Cause it can't be just anybody. So if your department has, you know, that identified, you know, wellness officer identified, bone support, whatever you want to call them. Maybe they could have a copy of your crisis plan. Or just sitting down as an exercise that everybody has their own crisis plan without sharing it. That might be fine too. And I like, I go through this with my patients, you know, with my physician patients you know, we will say, look, if this goes wrong, or if this happens, let's just go there. And let's write up a crisis plan - who you're going to call? What are you going to do? What, you know? And, and that crisis plan again, almost go through this visual exercise and you pick, you know, identify in their imagination, what might be the most difficult case they could encounter.

[00:21:49] Do this imagination exercise, you know, visualize it, visualize. Visualize, what is the most difficult case for them? Okay. And again, even the most difficult cases might be very different. [00:22:00] For somebody who most worst case might be, you know, a mother dying. For somebody might be a baby dying. For somebody might be both like, it's just so variable, right? Because what one person finds difficult and another person might find more tolerable, still difficult, but not as devastating. So that in itself, we can't assume what is difficult for non person is, you know, difficult for another.

[00:22:18] You know, what I do is visualize your difficult case, most difficult case that you can imagine again, what they can imagine. Honestly, what could happen. Right? Because our imagination is limitation. Visualize the most difficult case. Okay. How, what would you like to happen afterwards? Do you want to speak to a colleague? Do you want to take time off? How many hours do you think you need? Do you want to have access to a therapist? Do you have an existing therapist? Does he know, these days, luckily more people have, you know, existing therapist that they might need to be able to call or reconnect and, you know, again, uh, get ahold of right. Or know, who would they like to call? And the worst part [00:23:00] is Alicia is that when we tried to create this platitude support systems where we say, well, just call or we're, here's the number to call. And some of the worst issues are is when physicians do call or reach out, and the person who they reach out does not have the capacity to support a physician. Meaning, their skills is not up to par and they are too overwhelmed by what the physician might be telling. Because again, the physician might be disclosing, I had to deal with an infant deaths and the therapist might not be able to cope with that. And like you could tell, you know, people in distress can tell the therapist is overwhelmed by their distress.

[00:23:40] You know, recently I was speaking to a patient who was very frustrated because they disclosed suicidal thoughts to a therapist, the therapist was very overwhelmed. And that made the patient feel like, you know, there's just how much too much, right? Like, so again, and for physicians, the same thing. If we disclose something bad happening. If this therapist is [00:24:00] overwhelmed. It becomes very frustrating because, you know, as physicians, we feel like, okay, am I damaging therapist? Can this person actually helped me. They're overwhelmed. Like, why am I wasting time. So you do have to make sure that if you have a list of therapists or if you have a list of, you know, a number to call, that this number could actually validate and support the physician. And the therapist can actually provide containment and the help the physicians looking for. Rather than, oh, I can't believe this happened. And you know, the other thing is sometimes what happens with therapists is, as physicians, we have a very specific way of functioning, right? Like most of us work on sleep deprivation. Most of us work hours that are not regulated by unions, employment laws, or any of that stuff. So, if you are disclosing and discussing some kind you know, difficult demand, and the therapist [00:25:00] tries to tell you, why don't you work less hours or well don't you get a break, some of these very invalidating, unrealistic, unrelatable, advice -it becomes extremely frustrating because then you lose faith that this therapist can actually help you. Because they don't understand that part of the issue is a system that cannot be changed through the one person, or a person who is actually actively struggling you know, don't tell the struggling person to change the system by saying, you know, let's change our work hours. They're not in a place to change the department's work hours when they're struggling. And the therapist tells them, tell the department, to change your work hours. Most of us physicians have accepted this. Work hours that are not nine to five or union driven, or even five days a week. Again, most physicians work more than five days a week.

[00:25:52] So when you do come up with help to be listed on this crisis line. We have dug in, and be very realistic that [00:26:00] is this help actually help. There's nothing worse than we list a number or a person, and then somebody actually reaches out to them in distress. And the person's completely incapable of meeting that need, further making the physician feel like they're too much, that they're not understood or therapy is useless. I've seen a few male surgeons over my time. Right? Where they were reluctant about therapy because they didn't know the usefullness of therapy. Because again, they would feel like they're too much, right? Or what is actual therapy? And once they actually did therapy and they realize what therapy is and how it could be helpful. It a completely different story.

[00:26:43] But the most damaging thing is if they ever do reach out and the person on the other side tells well, why didn't you sleep or how come you work 30 hours or 24? That is a norm for physicians in certain areas. And that is not something we're going to be discussing in a crisis mode. But it [00:27:00] happens sometimes, you know, sometimes we'll get invalidated, very frustrated. Preemptively. Having a crisis plan. And on the crisis plan listing either people they can contact that are predictably available and capable of supporting them.

[00:27:15] That could be physicians, you know, other peer physicians that could be people who are paired up to be a peer supporter in your department. Again, if they choose to, not forced, appointed to be peer supportive. Trusted or existing therapists. Again, crisis lines as well, could be helpful. Cause they could be confidential. Non-physician crisis lines. Of course are very frustrating because again, the people might not understand the context, so that in itself had been validating. In the US, you know, a group of psychiatrists right, had started during COVID like a crisis line for physicians done by psychiatrists, which was extremely helpful. Unfortunately, we don't have anything [00:28:00] remotely similar in Canada. You know, I've tried to claw my way around it in Ontario and I got not far. And I've been told, well, you know, there's a crisis line provided by a third party. It's not done by physicians.

[00:28:16] Dr. Alicia Power: In BC, we've got a physician health program, which has a crisis line. So it's for physicians -

[00:28:21] Dr. Maryna Mammoliti: But is it by physicians?

[00:28:23] Dr. Alicia Power: Yeah.

[00:28:23] Dr. Maryna Mammoliti: Yeah. So that could be, like if it's done by physicians, it could be so much more helpful.

[00:28:29] Dr. Alicia Power: They were a bit overwhelmed and so the actual ability to do anything was weeks to months during COVID, but I think generally speaking, it is quite a productive. And quite a helpful -

[00:28:38] Dr. Maryna Mammoliti: But I think even just talking to a physician, like as a crisis call is very validating. Let aside from yeah, when they get into therapy. Yes. Absolutely. But I think even just that first phone call. When a peer takes it and, you know, validates it. It's such a big difference than when a non-physician answers and doesn't actually [00:29:00] understand the gravity of what you're dealing with you know, the systemic aspect. Why something is so tough for you.

[00:29:08] Dr. Alicia Power: Yeah. In terms of that being a department activity, I for some people that can be really challenging. So how would you frame that to a department and having the group of the department do that? Would you give them an exercise and send them home to do that individually? Or would you actually encourage them to do it as a group? If they're comfortable. I'm just imagining that would be very challenging as, that for some members of the department to do that.

[00:29:33] Dr. Maryna Mammoliti: If a department struggles to do that, that usually tells me that the department lacks emotional and psychological safety. If you really have to think about it, our department or group of physicians to work together, is kind of a place where you spend majority of your day, majority of your life for a certain number of years, because you literally spend so many [00:30:00] hours working as a physician, right? And as a physician, you really depend on each other in your department because you depend on them when you have a tough case or, at least you should feel comfortable to depend on your colleagues when you have a tough case, so you could ask for help. You depend on them to accommodate your needs, if you're sick and somebody has to cover your call shifts, a leave or whatever time you might need to take off, because you're sick, you have surgery, without punishment, right? You depend on them when there is badness happening, you know, again, peer support is the number one thing that makes a difference. When we have complicated cases when we have, you know, lawsuits, when we have complaints. We need peer support. We need to be validated by our peers. So if you really think about it, a department is like a family. Healthy families [00:31:00] have boundaries, healthy families also like a secure base where you can go to, to your older sibling or your parent, and you could get advice. You could get some support, you know, you feel safe when you pick up the phone and you call mom or dad. And after the phone call, you get off and you feel like, okay, I have some clarity I know to do.

[00:31:22] A healthy department is like that. And a healthy department has emotional safety, meaning that you could call up your colleague and say, listen, I'm not sure about this. Or, you know, listen. What do you think? You know, like that's a healthy department. In a health department, doing this as a, kind of a session wellness session for crisis planning for when we encounter bad events, should not be an issue. It could be you know, a couple hours with potentially a leader leading this, whether it's from the department, outside of the department ideally outside of the department, allow everybody in the department to be an equal and participate, but it should not be problem. [00:32:00] It should be fine.

[00:32:02] If we anticipate this is a problem, that means that this department does not necessarily have the psychological safety. And that means that there are members of the family who are either abusive, unpredictable, inconsistent, manipulative, threatening, whatever it may be, there are bad apples that make everybody else feel unsafe. Everybody else diminishes. So that's a bigger reflection on the department itself. Because if you're talking about supporting during bad times. Again, it's like, how do we expect a family to be source of support during financial stress or relationship issues somebody might having. If the family in itself has abuse and issues. Right. And so should the issue be a bigger discussion on identifying, you know, pathological behavior in the department? You know, again, like in psychiatry, do we need [00:33:00] family therapy before, we say you could rely and call on your brother or your mother. And sometimes, the department is just so unwell where it's like, the extent of sexual abuse between family members, you can't fix that family member. Like that's just not fixable. That that's not going to ever be a place of support. So it's the same in some departments, you know, some departments, the abuse between members is just so bad that animosity, the manipulation that, you know, everybody's just terrified that the department in itself is causing a vulnerability. So that when something bad happens, that physician cannot turn to the family for support, or even to rely with the families being supportive.

[00:33:47] So again, we have to be realistic. We can't live in a fantasy. We have to be realistic about what is the department like? Is this ever going to be a family where we could expect reasonable support. [00:34:00] Or there has to be some serious work on the department before we could even expect this. You know, because again, a lot of physicians feel very frustrated when some of these wellness initiatives are done. They're more platitudes. And when they actually try to use this, and it's either used against them or it's seen as again, they're weak or they're, or they're, whatever. And again, their vulnerability in using some kind of a wellness initiative is used against them months later. And it just traumatizes them even more. And again, w we can't expect true, genuine changes to come, if there's no emotional, psychological safety, or if somebody's using their safety plan is going to be used against them down the road.

[00:34:47] And, you know, and I've seen some departments could be very supportive and in some departments you could see it in Ontario, some department chairs reporting somebody taking time off from mental health to our college when it's [00:35:00] not mandatory, it's just shows the pathology in the department, because you know, you only have to report to the college if there is, you know, impairment, but if the physician preemptively says, look I'm going off on medical leave or I'm I need time off. That actually shows they're taking care of their mental or physical health, because it could be both. And for somebody to go and report that leave to the college, that shows potential vindictiveness, potentially trying to use that medical leave to get rid of somebody in the department. Potential lack of understanding of accommodation. Any disability on the person who's supposed to be running this department. If that is the chair of the department, with that little understanding of supporting wellness and health, how can this department have anything as wellness and health, and get the physicians trust. Cause when I mentioned psychological, emotional safety, that means that it's trust. I can [00:36:00] trust other people. I can trust that if I say something or I do something that they might not agree with, that I'm not going to have repercussions, punishment, dismissial. And to have an wellness initiatives, there has to be psychological safety, and emotional safety in department. We need that if I say, you know, this has been a tough case, I need to feel safe that weeks down the road, people are not talking about me in the corner. People not using my name with the residents to saying that I cracked. Or that I can't handle or that whatever else, because people have done it, you know, I've seen it all the time.

[00:36:40] Dr. Alicia Power: Yeah. What an interesting conversation we've gotten to. Thank you for chatting around this. I think this is really an important thing that we often, frankly, don't talk about as physicians. You do more than I do because you're in the business of helping physicians in their wellness journeys. But we've started off talking about radical [00:37:00] acceptance. And then we moved on to, okay, so now we know bad things are going to happen. That's just the nature of life. And that's the nature of the jobs that we have all chosen. How can we, if we need to modify what we're doing to, perhaps decrease that if that's what we feel we need. And then next, how do we look forward to the future to actually create an adverse event plan. Unexpected adverse event plan. And in a bigger sense, how do we know that we can rely on our peers to support us, who are those peers going to be? And if that's a department issue, then maybe we need to look at our department and the health and the wellness of our department as a whole, because that is, I think, often a big issue for some physicians, unfortunately. Thank you so much for having that discussion.

[00:37:47] Dr. Maryna Mammoliti: No. It's a pleasure. And again, an adverse event plan people should make it individual to them because they might have existing therapist. They might have existing support. So we don't have to closely enforce it.

[00:37:59] And sometimes adverse event plan might include like literally for them to have some time to walk their dog and their, you know, don't we can't under estimate pets. Like pets could be such a great source of support and distress tolerance for so many people. And it's just literally allowing people to individually think of, when you're having tough emotions and things are really tough. What do you do to do, to get through that?

[00:38:25] Because again, that's another emphasis, right? Cause there's positions where you, you know, expect to just suck it up and move on. Versus no, we're accepting radically accepting that you're going to have an emotional reaction after this event. It's totally normal to have a reaction. Your reaction is going to depend on the previous experiences. You know your own understanding of this. And, you know, so many personal factors as well as, again, some systemic factors, like, is it going to be college complaints going to be hospital complaints going to be this.

[00:38:54] What do you need? To tolerate those emotions and to get through that. Because again, [00:39:00] part of DBT is everything is temporary. Every badness is temporary. Like a wave, know, that initial wave of all emotions, fear, stuff like that is huge. And then it pipes up again when you know, hospital complainant, college complaint. If there is any or any funeral or anything else or any other kind of connection to that. Right. I just, what do you need to do when those waves come in?

[00:39:24] Dr. Alicia Power: That's awesome. Thank you so much for chatting with me today.

[00:39:27] Dr. Maryna Mammoliti: Well, it's been a pleasure. Thank you for connecting with me this morning.


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