WEBVTT 00:13.129 --> 00:15.209 [SPEAKER_00]: Hello and welcome back to Accrax. 00:15.590 --> 00:18.470 [SPEAKER_00]: I'm Jed Wolpa and we've got a fabulous show for you today. 00:18.610 --> 00:22.351 [SPEAKER_00]: One that I think is just crucially important and will make a big difference for a lot of people. 00:22.471 --> 00:29.753 [SPEAKER_00]: I have with me Dr. Sam D. Maria, he's a professor and vice chair for research in the Department of Anysiology at the Mount Sinai Health System. 00:30.033 --> 00:32.393 [SPEAKER_00]: And he recently published a book and it is fabulous. 00:32.433 --> 00:39.335 [SPEAKER_00]: I read it and just was totally into it called the invisible cut in civilities silent toll on healthcare. 00:39.915 --> 00:46.758 [SPEAKER_00]: And in the book, he challenges the ingrain belief that instability and medicine is simply an inconvenient part of the healthcare culture that we all experience. 00:47.138 --> 00:53.720 [SPEAKER_00]: He argues that even seemingly minor acts of disrespect are not just moral killers, but direct threats to patient safety. 00:54.080 --> 01:00.123 [SPEAKER_00]: The book is a comprehensive guide to understanding the root causes of instability and implementing tangible solutions. 01:00.503 --> 01:06.025 [SPEAKER_00]: He does a great job in the book of giving a lot of examples of solutions and things you can do, so I highly recommend you read it. 01:06.465 --> 01:09.348 [SPEAKER_00]: but we get to talk to him today and I'm very excited to do that. 01:09.408 --> 01:10.470 [SPEAKER_00]: So Sam, welcome to the show. 01:11.431 --> 01:12.852 [SPEAKER_00]: Yeah, thanks for having me here. 01:13.994 --> 01:16.336 [SPEAKER_00]: So fabulous job with the book. 01:16.396 --> 01:19.219 [SPEAKER_00]: Tell me a little bit about how you got to the point of writing this book. 01:19.259 --> 01:22.343 [SPEAKER_00]: How did you get interested in this topic and what pushed you to actually write a book on it? 01:23.355 --> 01:23.615 [SPEAKER_01]: Sure. 01:23.675 --> 01:39.992 [SPEAKER_01]: I think, you know, the short story is that I've been lecturing on this topic for the past five, six years or so, coming up with the heels of a study that I published with some colleagues about the effect of insubility on performance of anesthesia residents. 01:40.973 --> 01:44.717 [SPEAKER_01]: But really, I think my experience with insubility and healthcare starts 01:45.397 --> 01:50.200 [SPEAKER_01]: Probably where it starts for most people in medicine, which was as a medical student. 01:50.860 --> 02:01.446 [SPEAKER_01]: I opened the book with this because I think this was sort of a washer day of just the way most of us are introduced to the culture that still really exists in healthcare. 02:01.526 --> 02:03.187 [SPEAKER_01]: I was a third year medical student. 02:03.963 --> 02:08.186 [SPEAKER_01]: just really eager to get out in the clinical environment, very excited to do so. 02:08.206 --> 02:15.011 [SPEAKER_01]: I was on my surgery rotation, and I should say, as a background, I'm a pretty blue collar kid growing up. 02:15.111 --> 02:17.713 [SPEAKER_01]: I was used to sort of working on construction sites. 02:17.753 --> 02:19.655 [SPEAKER_01]: That's what with my dad's business was. 02:20.295 --> 02:24.799 [SPEAKER_01]: So I wasn't coming from a very gentle upbringing. 02:24.839 --> 02:29.442 [SPEAKER_01]: It wasn't something that was sort of a problem to me to work with, like, you know, tough people 02:31.363 --> 02:38.305 [SPEAKER_01]: But, you know, here I am in the morning, 7.30, I'm scrubbing up the sink, it's my first big case really on the basketball or surgery rotation. 02:38.325 --> 02:40.066 [SPEAKER_01]: It's going to be an open AAA. 02:40.606 --> 02:48.028 [SPEAKER_01]: And this little, you know, 5-foot tall, the 75-year-old surgeon kind of comes through and literally hit checks me out of the way. 02:48.048 --> 02:52.029 [SPEAKER_01]: And says, you're at my scrub sink, you know, and kind of just gives it to me. 02:52.089 --> 02:55.630 [SPEAKER_01]: And so they didn't tell you or you're just too stupid to remember that you don't scrub here. 02:56.270 --> 03:06.454 [SPEAKER_01]: And I just remember thinking like, well, if this happened in the grocery store, this would be a big problem, but this guy just sort of physically accosted me. 03:07.174 --> 03:10.795 [SPEAKER_01]: And the rest of that two week rotation on Vascular was more of the same. 03:11.055 --> 03:15.377 [SPEAKER_01]: This is at the time when you finally got 80 hour work weeks for the residents. 03:15.917 --> 03:22.159 [SPEAKER_01]: And I remember my Vascular fellow who was supervising me saying, well, those are the only apply to you guys as the med students. 03:23.081 --> 03:30.600 [SPEAKER_01]: So we're going to work at a death and they did, we were around to get foreign morning, changing the bandages, and then they would come in and tell us how badly we did. 03:31.615 --> 03:32.435 [SPEAKER_01]: and change them again. 03:32.455 --> 03:36.156 [SPEAKER_01]: And I just remember thinking, you know, I know where I am on the totem pole. 03:36.917 --> 03:39.957 [SPEAKER_01]: I don't need to be reminded physically and verbally every day. 03:39.977 --> 03:43.538 [SPEAKER_01]: And it got me really curious, like, why do we work like this? 03:43.598 --> 03:45.719 [SPEAKER_01]: Why do we treat each other this way? 03:45.739 --> 03:48.780 [SPEAKER_01]: I mean, this isn't really going to get the best performance out of me. 03:49.280 --> 03:52.301 [SPEAKER_01]: So, you know, I did, I think, well, most people that I sucked it up. 03:53.012 --> 03:55.233 [SPEAKER_01]: I grinned and I buried it and I needed it through. 03:56.153 --> 04:02.715 [SPEAKER_01]: And so this kind of really sparked in me, I think, an interest in just how we work, just generally thinking. 04:02.775 --> 04:08.257 [SPEAKER_01]: And when I ended up as an anesthesia resident, I was very, very involved in our research program. 04:08.977 --> 04:13.218 [SPEAKER_01]: And a simulation was a big part of the kind of research I was interested in. 04:13.238 --> 04:18.380 [SPEAKER_01]: It was a great lab, essentially, for studying how people perform, how they learned, 04:19.443 --> 04:42.242 [SPEAKER_01]: And over time when we did more and more performance-based sort of studies on anesthesia residents, anesthesia attendings, I thought this is a great place to really maybe quantify just how this kind of behavior affects the way we're performing because as a resident, I remember being in the operating room with assertive throwing things or screaming and just kind of afraid to speak up. 04:42.821 --> 04:48.325 [SPEAKER_01]: afraid to look over the drape and say, hey, did you want this antibiotic and said that this antibiotic? 04:49.005 --> 04:51.927 [SPEAKER_01]: And I knew that that just couldn't be good for us. 04:52.027 --> 04:57.891 [SPEAKER_01]: And so that kind of led to me sort of more formally, academically being interested in the topic. 04:58.931 --> 05:07.637 [SPEAKER_01]: Like I said, lecturing about this for the last five or six years really finally prompted me to put all my thoughts in one place, more or less, and put the book out. 05:08.339 --> 05:09.241 [SPEAKER_00]: Well, I'm so glad you did. 05:09.281 --> 05:10.523 [SPEAKER_00]: I think it's such an important topic. 05:10.803 --> 05:12.185 [SPEAKER_00]: I love the example you just gave of 05:13.348 --> 05:14.229 [SPEAKER_00]: being in the grocery store. 05:14.249 --> 05:25.415 [SPEAKER_00]: I mean, imagine you're at the cereal aisle, you're looking for your Cheerios that you want or whatever, and someone just comes in and literally pushes you out of the way and says, you know, how dare you? 05:25.455 --> 05:26.656 [SPEAKER_00]: That's my spot or something. 05:26.676 --> 05:38.443 [SPEAKER_00]: I mean, it's just inconceivable and yet, you know, it is at least at that time and you'll tell me if you think it's changed or not since then, but certainly that kind of thing was not uncommon back when 05:43.245 --> 05:47.648 [SPEAKER_00]: that level of, I mean, there's certainly instability. 05:47.748 --> 05:58.034 [SPEAKER_00]: I mean, we actually have had some experiences with folks being doing their pre-operative interview with a patient and having the 05:58.774 --> 06:04.736 [SPEAKER_00]: attending surgeon walk up and just interrupt mid-sentence and start talking as if no one else was there. 06:05.556 --> 06:16.220 [SPEAKER_00]: It's not common in my experience but it has happened and you know so that's not physical but it's still very rude verbally so but do you think the physical stuff is still happening like where are we compared to when that happened to you? 06:17.020 --> 06:26.844 [SPEAKER_01]: Sure I mean I think overall we've got a better sense of culture in in healthcare moving in a more civil direction. 06:26.964 --> 06:27.224 [SPEAKER_01]: I think 06:28.152 --> 06:38.156 [SPEAKER_01]: At least physically, you know, really the days of surgeons throwing their instruments are probably long behind us outside of a handful of small pockets. 06:39.757 --> 06:45.739 [SPEAKER_01]: And certainly, you know, there's never a place for what amounts to workplace violence if it's a physical act. 06:48.390 --> 06:53.695 [SPEAKER_01]: But more common now is sort of the verbal abuse. 06:53.835 --> 06:56.577 [SPEAKER_01]: And I'm not sure that we've got a good handle on that. 06:56.597 --> 07:08.147 [SPEAKER_01]: In fact, there have been recent studies largely out of the nursing literature showing that especially since the pandemic, the instance of a verbal abuse has actually gone up. 07:09.537 --> 07:14.901 [SPEAKER_01]: But because we're seeing a very stressed health care workforce, these are very burnt out people. 07:15.641 --> 07:21.825 [SPEAKER_01]: And again, not making the excuse for it, but not everybody is self-actualized, that is realizing what they're doing. 07:21.865 --> 07:25.327 [SPEAKER_01]: So I think a lot of times people are lashing out. 07:25.387 --> 07:27.088 [SPEAKER_01]: And this was always a big message of mind. 07:27.348 --> 07:33.692 [SPEAKER_01]: When talking about this, we're all guilty of instability at some point, delivering instability. 07:35.053 --> 07:37.715 [SPEAKER_01]: And we're all vulnerable to it when it happens to us. 07:38.527 --> 07:44.630 [SPEAKER_01]: And because of that, it's just a shared experience that we can all work on together and try to fix. 07:45.270 --> 07:48.171 [SPEAKER_01]: But I don't think that it's going away anytime soon. 07:48.811 --> 07:52.993 [SPEAKER_01]: I think that, you know, if anything, health care is getting more and more stressful. 07:53.574 --> 07:58.696 [SPEAKER_01]: And so we're not necessarily coaching people to sort of work on this. 07:59.536 --> 08:03.658 [SPEAKER_01]: We might be even be rewarding many people in the workforce. 08:04.535 --> 08:06.837 [SPEAKER_00]: Yeah, so let's talk about why this is so pervasive. 08:06.957 --> 08:07.898 [SPEAKER_00]: I mean, do you have a feel for that? 08:07.998 --> 08:10.460 [SPEAKER_00]: Why is it so pervasive and underestimated? 08:10.500 --> 08:13.522 [SPEAKER_00]: What's going on in our in our world of medicine? 08:13.562 --> 08:13.742 [SPEAKER_00]: Yeah. 08:14.202 --> 08:14.503 [SPEAKER_01]: Yeah. 08:14.523 --> 08:17.385 [SPEAKER_01]: I mean, if you look at the corporate literature on this. 08:18.405 --> 08:28.511 [SPEAKER_01]: and Christine Porath is a real expert in this as written really extensively in the literature about it, and it's all corporate workplace, legal workplace. 08:29.412 --> 08:39.458 [SPEAKER_01]: There are two real reasons why people just very broadly speaking will commit acts of harassment, instability, disrespect in the workplace. 08:40.679 --> 08:47.203 [SPEAKER_01]: One is literally just fear, many times people are fearful of things that aren't probably on the surface. 08:47.243 --> 09:05.335 [SPEAKER_01]: The example I always give about our surgical colleagues is the reason that they're at the front desk stomping their feet and asking why their room is delayed is because they feel that if they don't do that, that they will sort of lose something, that they're worried that you're going to sort of take advantage of them. 09:06.476 --> 09:10.411 [SPEAKER_01]: if they don't kind of make it known that this is not the kind of thing that they're going to tolerate. 09:11.584 --> 09:16.387 [SPEAKER_01]: So, fears of big part, and then stress in burnout are usually the second part of that. 09:16.447 --> 09:27.633 [SPEAKER_01]: And as I already alluded to, and as I think everyone listening to this podcast knows, burnout health care is not something that is alien to anybody. 09:27.733 --> 09:38.419 [SPEAKER_01]: It's probably not something we've got a great handle on fixing, a lot of times we talk about resilience as a way of sort of almost passing the buck on our colleagues. 09:39.860 --> 09:52.588 [SPEAKER_01]: bring them granola bars and bring it all into the office space and say, what, we're working, we're helping you're wellness, but, you know, wellness and burnout is a little deeper issue of just sort of a handful of creature comforts at work. 09:52.648 --> 10:05.396 [SPEAKER_01]: And so now you take the two of these things and you put them together and you take a very stressed workforce and you take a very fearful workforce and you get a lot of sort of lashing out and that's usually 10:10.166 --> 10:15.233 [SPEAKER_01]: There's an added layer that's been shown and this is true elsewhere, but very, very true in healthcare. 10:15.834 --> 10:24.146 [SPEAKER_01]: We've got this sort of brilliant jerk phenomenon where we've got people who are highly skilled and who have sort of habituated. 10:24.883 --> 10:52.720 [SPEAKER_01]: to abusing others around them to get their way and because they are these brilliant Turks, people say, well, so and so can say whatever they want because they're the, you know, you name it, Chair of the Department, that's the anesthesiologist in the world, best surgeon in the world, and they kind of get a pass, and that's really athletic building, positive reinforcement loop that allows them to think that this behavior is actually helping them. 10:53.738 --> 11:18.079 [SPEAKER_00]: Yeah, yeah, it's really multifactorial and all the things you went over it just resonate absolutely I think you know you've got People let's just look at surgeons for a minute right you got surgeons who are going through a very grueling Challenging training where they are often getting treated badly and burned out and then they become attendings and they are in a situation where it is seemingly permitted to lash out 11:18.699 --> 11:21.540 [SPEAKER_00]: plus they're being put in a stressful environment in the OR. 11:21.921 --> 11:23.121 [SPEAKER_00]: So they're now stressed out. 11:23.621 --> 11:25.662 [SPEAKER_00]: And then there are stereo types, right? 11:25.682 --> 11:32.005 [SPEAKER_00]: So you've got four just when I'm thinking about the surgeon anesthesiologist, relationship, you've got these stereotype of the anesthesiologist who doesn't really care. 11:32.045 --> 11:33.626 [SPEAKER_00]: They're just doing their Sudoku over there. 11:34.026 --> 11:36.167 [SPEAKER_00]: And so it's an easy target to lash out at. 11:36.187 --> 11:38.528 [SPEAKER_00]: I mean, there's so many things that lead into this. 11:38.548 --> 11:40.869 [SPEAKER_00]: Which, of course, makes it all the harder to address. 11:42.390 --> 11:50.956 [SPEAKER_00]: But let's back up a second and let me ask you why, I mean, this is obviously I don't believe that it's unimportant, but let's just ask the question, why do we care? 11:51.296 --> 12:07.546 [SPEAKER_00]: So, you know, give us the reason why this is bad because it sounds bad, but you know, what if what if being people being jerks didn't actually have any effect on anything, then we wouldn't maybe care, or maybe we'd say it's not that big of a video, but we do, so why? 12:07.626 --> 12:08.527 [SPEAKER_00]: Why is this a big deal? 12:09.270 --> 12:14.140 [SPEAKER_01]: Sure, yeah, I think this is a great place to start because I think 12:15.355 --> 12:22.078 [SPEAKER_01]: It's a nice thought experiment to say, let's say we're being just overly sensitive for lack of a better, more accurate term. 12:22.919 --> 12:24.239 [SPEAKER_01]: Does this reach the patient? 12:24.699 --> 12:31.503 [SPEAKER_01]: Is it really the question, I think we want to ask ourselves, because we know that if you work in a hostile environment, you're going to quit. 12:31.883 --> 12:32.843 [SPEAKER_01]: You're going to go somewhere else. 12:32.903 --> 12:39.366 [SPEAKER_01]: But I was more concerned with the patient, does the patient really experience this? 12:39.966 --> 12:43.088 [SPEAKER_01]: So there's a lot of data that's very tangential. 12:44.625 --> 12:52.010 [SPEAKER_01]: certainly Cooper and Vanderbilt's published quite a bit of this, looking at, and again, I'm not picking on the surgeons here. 12:52.130 --> 12:57.214 [SPEAKER_01]: I have a lot of great friends who are surgeons, but you know, we're anesthesiologists, so like that's sort of our main counterpart. 12:57.254 --> 13:00.277 [SPEAKER_01]: This is true and pervasive across disciplines. 13:01.638 --> 13:06.842 [SPEAKER_01]: But if you look at surgeons who have a higher level of professional complaints, 13:08.178 --> 13:14.303 [SPEAKER_01]: those surgeons have patients who tend to have more morbid and outcomes following surgery. 13:14.963 --> 13:17.145 [SPEAKER_01]: That sort of strange if you think about it, right? 13:17.165 --> 13:20.908 [SPEAKER_01]: Because many times it's hard to connect one to the other. 13:20.988 --> 13:22.609 [SPEAKER_01]: Now we've got lots of data like that. 13:22.689 --> 13:36.840 [SPEAKER_01]: That's very, very sort of blasting at the problem that's shows that in surgery and medicine, in critical care and lots of other settings, certainly in the emergency department we see this as well in the data, that when you have the professionals who have a lot of professional misconduct, 13:37.370 --> 13:39.291 [SPEAKER_01]: their patients just have worse outcome. 13:39.931 --> 13:50.615 [SPEAKER_01]: Now, I'm the sort of big paper on this by Cooper and Gemma, they sort of, I think, overinterpreted their results, but I like their interpretation because it works to my benefit for when I give the talk. 13:51.535 --> 13:56.397 [SPEAKER_01]: And they said that it's likely that these individuals create a culture, 13:57.583 --> 13:59.704 [SPEAKER_01]: That makes it very hard to care for their patients. 13:59.744 --> 14:12.128 [SPEAKER_01]: So let's say they're masterful surgeon at what they do, but maybe postoperatively something happens on the floor and the nursing team is afraid to call the service and say, this is happening, that's happening. 14:12.468 --> 14:15.609 [SPEAKER_01]: My delay care might make poor outcomes. 14:15.629 --> 14:18.050 [SPEAKER_01]: So again, we've got some real-world data. 14:18.270 --> 14:22.792 [SPEAKER_01]: It's not really possible to, or ethical even to study this in a way. 14:23.574 --> 14:24.555 [SPEAKER_01]: that connects the dots. 14:25.075 --> 14:37.782 [SPEAKER_01]: Then there was a paper in the pediatric ICU literature that showed that if you have some code teams, you know, dealing with a simulated crisis, and you introduce a person, 14:38.590 --> 14:42.712 [SPEAKER_01]: who is very distracting and sort of a rude and dismissive way. 14:42.772 --> 14:53.178 [SPEAKER_01]: Someone's just suggesting things in a way that's very aggressive or really just sort of like full sort of disdain for the group there, the group's performed worse. 14:54.339 --> 15:01.043 [SPEAKER_01]: And so sort of the amalgamation of this from my group is like, why don't we do a study where we kind of do the same thing with 15:02.448 --> 15:15.820 [SPEAKER_01]: our anesthesia residents because as you point out they're the one in the the operating room a lot of times and while we're running around as attendees doing other things so they have a lot more anesthesia hours in a way than your average academic attending does. 15:15.900 --> 15:20.505 [SPEAKER_01]: And so we took them in we used the validated scenario that we have which is sort of 15:21.488 --> 15:30.014 [SPEAKER_01]: an occult hemorrhage on them, otherwise totally healthy person that just refractory to every kind of treatment that they bring in. 15:30.594 --> 15:33.757 [SPEAKER_01]: And it's just a lot for Scott Beck, GYN, and something kind of case. 15:34.377 --> 15:41.382 [SPEAKER_01]: And they're randomized either to a surgeon who's very nice, and very communicative, or a surgeon who is very rude to everyone in the room. 15:42.302 --> 15:43.143 [SPEAKER_01]: But nothing's sort of... 15:43.956 --> 16:10.521 [SPEAKER_01]: overboard to sort of like all the insulators not working why can't I get good equipment in this place the patient's fighting me what's wrong with you just give more of real acts of that kind of stuff no swearing, no throwing of things just sort of run of the mill instability and what we found was on all the domains that we measured the group that was exposed to simulated instability and again remember they know this is a simulated environment they know that this isn't a real 16:12.543 --> 16:25.828 [SPEAKER_01]: But on every domain that we measure, whether those are medical and technical domains, whether those are communication and behavioral domains, their performance was significantly lower than the group that had a surgeon that was communicative. 16:26.909 --> 16:35.712 [SPEAKER_01]: We didn't do the qualitative part of this, but on the videos you could see like a lot more communication happening with a surgeon that they sort of felt comfortable with. 16:36.906 --> 16:50.955 [SPEAKER_01]: And in each case, when our blinded raiders rated them at the end, the instability exposed residents were rated as just lower overall, just on a global performance rating of sort of, would you let this person take care of a family member? 16:51.716 --> 16:53.357 [SPEAKER_01]: We really push these people to the end. 16:53.377 --> 16:56.619 [SPEAKER_01]: They missed simple things, you know, you have a hypotensive patient. 16:57.139 --> 17:00.321 [SPEAKER_01]: You'd think that you want to turn the anesthesia down or maybe start a 17:04.173 --> 17:27.498 [SPEAKER_01]: very complicated stuff like communicating with the surgeons to say hey maybe you need some help can you can you look around and see if you hit something the whole thing sort of fell apart the sort of rattled cage phenomenon of of performance and we've done some follow-up studies we're doing some ongoing ones now on different aspects of this issue and I will tell you that it 17:34.160 --> 17:44.380 [SPEAKER_01]: problem solving, decision making, everything that you could think of preoperatively, intraoperatively, and we're really just starting to crack the hood on this, I think. 17:45.414 --> 18:02.879 [SPEAKER_00]: very interesting, you know, what's fascinating is that it makes sense that if the surgeon is being, you know, kind of aggressive and not particularly nice, you may not be comfortable or I would totally imagine that residents in the simulation would not maybe ask the surgeon things or communicate as well with the surgeon. 18:03.159 --> 18:04.099 [SPEAKER_00]: But the fact that they, 18:05.302 --> 18:06.883 [SPEAKER_00]: things that had nothing to do with the surgeon, right? 18:06.943 --> 18:08.304 [SPEAKER_00]: So like, addressing hypotension. 18:09.565 --> 18:12.627 [SPEAKER_00]: The fact that they had decrements in that is really fascinating. 18:13.207 --> 18:24.174 [SPEAKER_00]: And I think must have to do with the fact that when you're feeling that just discomfort and that insibility, you, maybe you're sitting there ruminating about it, thinking like, what happened here? 18:24.214 --> 18:24.834 [SPEAKER_00]: Did I do something wrong? 18:24.874 --> 18:26.915 [SPEAKER_00]: Or you're just feeling a little shut down or stressed? 18:26.955 --> 18:30.918 [SPEAKER_00]: And you don't focus on the things you would normally focus on, does that kind of ring true? 18:31.718 --> 18:41.304 [SPEAKER_01]: Yeah, I mean, that's really where I think this becomes interesting is as you said, we expected actually communication and teamwork to go down. 18:41.324 --> 18:42.905 [SPEAKER_01]: That was expected. 18:42.945 --> 18:50.510 [SPEAKER_01]: What we didn't really expect or didn't know what to expect was this other sort of nitty-gritty medical decision-making stuff. 18:50.590 --> 18:51.591 [SPEAKER_01]: And I always tell people, 18:52.598 --> 19:01.846 [SPEAKER_01]: The most likely reason from a cognitive psychotic, you know, a performance sort of psychology standpoint is this, is just workload. 19:02.086 --> 19:16.698 [SPEAKER_01]: You know, if you're driving your car into the shopping center and it's snowing and the wind is blowing and it's really hard to see and your babies in the XC and they're crying and you've got the radio on, 19:17.519 --> 19:39.182 [SPEAKER_01]: Most people when they're doing that and they're looking for a parking spot The first thing they will do is turn the radio down and they've actually studied this and it's fascinating stuff But why do they do that because we know instinctively that when our workload is too high our performance will suffer on whatever task we're doing So you turn the radio down 19:40.152 --> 19:42.235 [SPEAKER_01]: so that you can drive the car into a spot. 19:42.636 --> 19:49.406 [SPEAKER_01]: It's kind of the same thing in this case, you can't really turn this radio down, you can't turn this in civil surgeon down. 19:49.506 --> 19:55.135 [SPEAKER_01]: They're just making everything worse, and then your workload goes through the roof above the threshold. 19:58.067 --> 20:01.473 [SPEAKER_01]: But above a threshold at which you can perform really, really well. 20:02.074 --> 20:08.045 [SPEAKER_01]: And you start to just sort of degrade your performance in other domains that aren't just communication. 20:08.526 --> 20:11.051 [SPEAKER_01]: And this is not really a surprise, I think. 20:12.263 --> 20:30.900 [SPEAKER_01]: When you look at sort of what we are evolved to do and I spent a lot of time in the book talking about the evolution of humanity, just in general, and it's a big part of what we do is communicate well, collaborate well, and we're very pro-social primates, right? 20:30.920 --> 20:35.584 [SPEAKER_01]: And so we're not really wired for anti-social behavior when we encounter something. 20:36.326 --> 20:37.527 [SPEAKER_01]: that is anti-social. 20:37.968 --> 20:39.929 [SPEAKER_01]: It really rattles us and throws us off. 20:39.949 --> 20:47.856 [SPEAKER_01]: And it's exactly what happens in acute crisis like this when you've got, you know, a bit of a jerk on the other side of the drape. 20:48.517 --> 20:54.822 [SPEAKER_00]: Yeah, yeah, that is I think exactly right and it makes total sense that, you know, I think you, you talk about in the book, how 20:55.962 --> 21:00.403 [SPEAKER_00]: human beings from very early on were dependent on civility. 21:00.423 --> 21:12.107 [SPEAKER_00]: I mean, that's how we survive by having a tight-knit group, a tribe that people supported each other and that if you were not receiving that support from the group, it was incredibly dangerous. 21:12.127 --> 21:15.008 [SPEAKER_00]: You would potentially be outcast and would die. 21:15.568 --> 21:20.069 [SPEAKER_00]: And so, you know, building that civil interaction is built into us, as you say. 21:20.870 --> 21:21.690 [SPEAKER_00]: But let's talk about 21:22.669 --> 21:25.171 [SPEAKER_00]: how we address this problem. 21:25.591 --> 21:28.693 [SPEAKER_00]: So you go over a lot of really interesting frameworks in the book. 21:29.314 --> 21:35.799 [SPEAKER_00]: Talk about kind of the micro interventions that every individual can use to try to foster a more civil environment. 21:37.260 --> 21:37.480 [SPEAKER_01]: Sure. 21:37.900 --> 21:41.323 [SPEAKER_01]: I think I'll start with the less cynical. 21:42.853 --> 21:49.598 [SPEAKER_01]: approach first and then we can give a little bit of cynicism to this because I'm a New York guy we have a little cynicism. 21:50.819 --> 21:56.943 [SPEAKER_01]: First I think it does start with the individual, it starts with us, you can really only control what you can control. 21:56.983 --> 22:09.452 [SPEAKER_01]: The world's always going to put things in your way, you're always going to have a versity and certainly I'm not an advocate for someone speaks to you in a way that you don't like in the middle of a crisis because they were nervous and you were nervous 22:10.832 --> 22:15.695 [SPEAKER_01]: You should, you know, get their head on a pike because they may have time to do. 22:15.715 --> 22:17.456 [SPEAKER_01]: We're not talking about simple offense. 22:17.716 --> 22:22.439 [SPEAKER_01]: I think none of us should be arrogant enough in our ego that we don't take for a little while. 22:22.479 --> 22:24.620 [SPEAKER_01]: We think we're going to live a life where people don't attend us. 22:25.440 --> 22:33.905 [SPEAKER_01]: But we've never had a time in our, in our, in our, the arc of our history where we've been less and good at social interactions. 22:35.187 --> 22:42.172 [SPEAKER_01]: The phones in our pockets, the computers that were on all day, we're stepped out of so many social situations. 22:42.753 --> 22:44.854 [SPEAKER_01]: But we just don't get the reps like we used to. 22:46.115 --> 22:49.678 [SPEAKER_01]: So certainly it starts with us trying to communicate better. 22:50.219 --> 22:55.403 [SPEAKER_01]: And on the anesthesia side of things, that means we shouldn't be this passive aggressive specialty. 22:55.463 --> 22:57.585 [SPEAKER_01]: We shouldn't put the drape up as high as we can. 22:58.231 --> 23:05.257 [SPEAKER_01]: we should talk to the people in the operating room and set the tone for the kind of culture that we want in the OR. 23:05.597 --> 23:17.827 [SPEAKER_01]: It's very convenient to say the surgeons bring the cases and we're just sort of in a consultant role and because that allows you to just kind of duck out of it and be a part of building the culture. 23:18.407 --> 23:22.250 [SPEAKER_01]: But I certainly see the surgical residents as my residence 23:23.855 --> 23:49.232 [SPEAKER_01]: And they've learned in my operating room sort of how we deal with each other and that's not sort of a draconian thing That's just we're friendly we get to know each other and I'm not an extraverted kind of person I'm not interested in grabbing a cocktail with with most of my surgical colleagues after work I just want to make sure we're on the same team that we're collaborating really well And that they can tell me their concerns and I can tell them my concerns so 23:50.030 --> 24:02.634 [SPEAKER_01]: We have to really work very hard as a specialty in individually that's how we start it by showing up in the operating room in a way where we are sort of the leaders of the kind of culture that we want. 24:03.535 --> 24:10.777 [SPEAKER_01]: Now, there are environments that are not going to be amenable to our charms for lack of a better term. 24:11.432 --> 24:26.464 [SPEAKER_01]: So the cynical part of this is, I'm a very big fan of, it's an old book, but it's a good book, and I always recommend it to people that call never split the difference by Voss. 24:26.544 --> 24:37.773 [SPEAKER_01]: He's an FBI hostage negotiator, and it's a great book for whether you're going to buy a new car or a house, and it's also a great book for the operating room. 24:38.327 --> 24:42.149 [SPEAKER_01]: And there are lots of really cool psychological tricks and tactics in there. 24:42.169 --> 24:46.312 [SPEAKER_01]: It's sort of under the bucket of what he would call tactical empathy. 24:47.272 --> 24:58.119 [SPEAKER_01]: For how to deal with people who might not be the easiest to deal with, things like mirroring the kind of words that they say, or giving them psychological outs. 24:58.239 --> 25:02.961 [SPEAKER_01]: Like, you know, if a surgeon says to me, you know, let's say a patient comes in and they have seven 25:08.033 --> 25:11.635 [SPEAKER_01]: And for whatever reason, the wires got across to the, they're all they're aspirin. 25:11.675 --> 25:15.397 [SPEAKER_01]: Something I think we deal with quite a bit in, in anesthesia practice. 25:15.697 --> 25:20.819 [SPEAKER_01]: And it's an elective case and they could very easily be postponed and come back when it's safe to do so. 25:20.839 --> 25:24.501 [SPEAKER_01]: And the surgeon, you know, is, is sort of pushing back. 25:25.806 --> 25:28.807 [SPEAKER_01]: You know, he's got tactics in there that you say I'm sure. 25:28.867 --> 25:34.289 [SPEAKER_01]: I know you're not trying to suggest anything XYZ so I know you're not trying to say anything unsafe. 25:34.569 --> 25:45.413 [SPEAKER_01]: I totally get where you're coming from But my concern is that we're gonna do this elective case on someone who really shouldn't have it done today This is against every guideline. 25:45.453 --> 25:49.495 [SPEAKER_01]: We have it's potentially malpractice in the making and 25:50.292 --> 25:52.394 [SPEAKER_01]: I think that we should really cancel this case. 25:52.894 --> 26:07.445 [SPEAKER_01]: And so a lot of it is just these very, very interesting ways to, I don't want to say, play on people's psychology, but certainly Ben Franklin knew that if you ask people to do favors for you, they're more not likely to do them for you. 26:07.505 --> 26:14.891 [SPEAKER_01]: And they're more likely to do them for you in the future because it sets them up in their own mind, as I'm the kind of person who does favors for you. 26:15.011 --> 26:17.353 [SPEAKER_01]: And the cognitive dissonance of not doing a favor for you, 26:18.068 --> 26:19.969 [SPEAKER_01]: um, prevents them from doing it in the future. 26:20.009 --> 26:35.620 [SPEAKER_01]: So this is just tactical empathy, um, and the cynic in me says you should learn a few of these because you're going to encounter people in your work environment, who aren't necessarily interested in playing on the same team, and you should know how to handle them at the micro level. 26:36.767 --> 26:52.817 [SPEAKER_00]: yeah and there's a great interview by the way of that author voss uh... about this same topic uh... by very wise on the podcast honestly so folks can check that out to stay with us will be right back all right and we're back 26:55.687 --> 27:04.463 [SPEAKER_00]: What if you're a resident, you know, you're a resident, maybe you're a first year resident, and you're in the OR with a very senior surgeon who is being in civil. 27:05.204 --> 27:05.284 [SPEAKER_00]: How? 27:07.915 --> 27:09.576 [SPEAKER_00]: do you address that is that the same. 27:09.696 --> 27:15.821 [SPEAKER_00]: I mean, you recommend using kind of the same technique and language, which I think is a lot harder if you're a junior person. 27:16.902 --> 27:23.687 [SPEAKER_00]: I mean, I think it's hard for anybody, even attending anesthesiologist, but I think it's even harder for a junior resident or are there other ways or do they not? 27:23.727 --> 27:28.430 [SPEAKER_00]: Do they need to just call their attending and say, you know, I'm feeling like the surgeon is being, you know, in civil. 27:29.831 --> 27:35.655 [SPEAKER_01]: Yeah, certainly, it's interesting there's even been a study on putting residents 27:38.525 --> 27:53.711 [SPEAKER_01]: and then exposing them to suitability, again in the simulated environment, and showing that they actually improve their ability to communicate with someone who's being a little inappropriate. 27:54.811 --> 27:57.532 [SPEAKER_01]: I think it's a couple of things for the residents. 27:58.233 --> 27:58.953 [SPEAKER_01]: Yes, there's this 27:59.872 --> 28:05.135 [SPEAKER_01]: understood hierarchy which might make them feel powerless. 28:06.016 --> 28:07.377 [SPEAKER_01]: But certainly that's not the case. 28:07.437 --> 28:16.442 [SPEAKER_01]: So you really do have to convince yourself that the behavior that you're seeing around you if it's in civil is going to reach the patient. 28:16.742 --> 28:17.923 [SPEAKER_01]: It's bad for the patient. 28:19.024 --> 28:26.628 [SPEAKER_01]: So sometimes it's a deep breath, maybe it's a little bit of a pep talk to yourself that you're going to have to stand up and you're going to have to say something 28:31.154 --> 28:55.391 [SPEAKER_01]: And I do recommend actually on my often tell our residents that I do think that they should think about the dynamics of the operating room as much of a subject to be studied and read about and learn as they would the volume of distribution remedy fentanyl right so I think yes the vast book is a great place to start. 28:56.262 --> 28:56.742 [SPEAKER_01]: for sure. 28:57.783 --> 29:03.707 [SPEAKER_01]: I think any bit of YouTube TED Talk from Christine R.F. 29:03.747 --> 29:13.674 [SPEAKER_01]: is important because I think she's really masterfully identified and summated how instability really hurts our work performance. 29:14.515 --> 29:22.460 [SPEAKER_01]: And I think they really do have to during their attendees in and I'm a big fan of 29:23.878 --> 29:41.271 [SPEAKER_01]: having a good conversation with your surgical colleagues when you can and never to weaponize reporting because I hate that and when you see that somebody fills out one of those event things for nothing at all but when things get to a point where you really do feel that this is inappropriate. 29:41.291 --> 29:45.314 [SPEAKER_01]: I know it's physicians for some reason we always feel like if we use these 29:53.578 --> 30:00.163 [SPEAKER_01]: systems that are in place for event reporting when we think things have crossed over the line. 30:00.203 --> 30:12.811 [SPEAKER_01]: So try everything you can in your tower, obviously, bring in your supervisor, your attending, your chair, whoever you have to bring in, but don't be afraid to use the systems that are available to you. 30:12.871 --> 30:17.674 [SPEAKER_01]: And certainly at the time, we have this, they call it a cup of coffee, it 30:20.536 --> 30:28.300 [SPEAKER_01]: If someone has a professionalism complete about, you know, against them, they actually sit down with a colleague who's in their specialty. 30:29.501 --> 30:31.122 [SPEAKER_01]: I guess potentially over a couple of coffee. 30:31.142 --> 30:32.883 [SPEAKER_01]: I've never had one thing fully, so I don't know. 30:33.203 --> 30:39.446 [SPEAKER_01]: But, and they kind of just talk it through as opposed to just setting you right to anger management or something that way. 30:39.987 --> 30:43.508 [SPEAKER_01]: And I think that the program is fairly successful. 30:43.648 --> 30:46.310 [SPEAKER_01]: So it's one of those rare instances, I think. 30:47.117 --> 31:03.124 [SPEAKER_01]: where some of this red tape kind of reporting system stuff does help people get the sense of like hey, your behaviors really aren't where they need to be and this is a warning and you're sort of on the radar and for some people it does help. 31:04.004 --> 31:06.345 [SPEAKER_00]: Yeah, yeah, I think that's really important and to 31:13.192 --> 31:19.795 [SPEAKER_00]: made a physical kind of a transgression, right? 31:20.276 --> 31:26.619 [SPEAKER_00]: So if somebody, you know, threw something at somebody, then you would, I think most people would say, yeah, we need to write that up as an event. 31:27.079 --> 31:30.400 [SPEAKER_00]: But, you know, the insibility part is just verbal. 31:30.440 --> 31:33.322 [SPEAKER_00]: I think people are less likely to, but it's just as important. 31:34.042 --> 31:37.344 [SPEAKER_00]: So let's do maybe a couple of sort of semi-roll plays. 31:37.384 --> 31:39.145 [SPEAKER_00]: I mean, let's say that I'm a resident, 31:39.905 --> 31:47.789 [SPEAKER_00]: I'm in the OR, and I'm with a surgeon who is just saying things like, he's going to say, oh, you know, the patient is clearly awake. 31:47.809 --> 31:48.489 [SPEAKER_00]: They're moving. 31:48.529 --> 31:49.489 [SPEAKER_00]: What's the matter with you? 31:49.769 --> 31:51.990 [SPEAKER_00]: You know, I thought we agreed zero twitches. 31:52.391 --> 31:53.851 [SPEAKER_00]: Are you even paying attention back there? 31:54.331 --> 31:55.572 [SPEAKER_00]: You know, they're not swearing. 31:55.632 --> 31:56.232 [SPEAKER_00]: They're not throwing. 31:56.252 --> 31:56.893 [SPEAKER_00]: They're not yelling. 31:56.933 --> 31:58.673 [SPEAKER_00]: They're just making these kind of disparaging comments. 31:59.254 --> 32:00.614 [SPEAKER_00]: You're, let's say that you're my attending. 32:00.634 --> 32:01.375 [SPEAKER_00]: You're not the room with me. 32:01.695 --> 32:05.216 [SPEAKER_00]: But let's say you were like on my shoulder as a little, you know, a little angel. 32:05.596 --> 32:06.557 [SPEAKER_00]: And you're whispering in my ear. 32:06.577 --> 32:07.097 [SPEAKER_00]: What would you tell 32:10.557 --> 32:28.702 [SPEAKER_01]: Yeah, I think it starts really with, with, to fusing some of the situation, a big part of it is, again, remember this person, probably at this point, what's driving there, their complaints, let's assume, by the way, zero twitches, you just gave a hundred of rock deronium, three minutes ago, right? 32:30.503 --> 32:33.664 [SPEAKER_01]: What's driving them right now is essentially fear and stress, right? 32:33.684 --> 32:34.744 [SPEAKER_01]: There's something going wrong. 32:35.785 --> 32:38.707 [SPEAKER_01]: There they're having trouble getting exposure or whatever it is. 32:38.748 --> 32:40.249 [SPEAKER_01]: We've all started seeing that, right? 32:41.730 --> 32:48.397 [SPEAKER_01]: And I'm not going to suggest that I've ever, ever, ever given the slowest sailing that we used to get taught to give 32:52.930 --> 32:53.591 [SPEAKER_01]: or a young board. 32:54.411 --> 33:00.655 [SPEAKER_01]: But I do think it starts by standing up and saying, okay, what's going on? 33:01.536 --> 33:02.937 [SPEAKER_01]: Patients moving all over the place. 33:03.537 --> 33:06.659 [SPEAKER_01]: That's something that maybe there is something you don't know. 33:06.719 --> 33:07.580 [SPEAKER_01]: That's another thing. 33:07.660 --> 33:08.460 [SPEAKER_01]: Maybe be open. 33:09.461 --> 33:15.305 [SPEAKER_01]: Remember, your surgeons are stressed out because they're stapled to the floor in a way that we aren't. 33:15.345 --> 33:17.006 [SPEAKER_01]: We get to move our bodies a little bit. 33:17.026 --> 33:18.307 [SPEAKER_01]: We can grab things and do stuff. 33:18.347 --> 33:20.268 [SPEAKER_01]: They just got their ones put one position. 33:21.199 --> 33:26.020 [SPEAKER_01]: And they're focused in their one area, and that can be really, really stressful just physically for them. 33:26.500 --> 33:30.962 [SPEAKER_01]: And so it starts by actually maybe hearing out the diaphragm is moving all over the place. 33:31.002 --> 33:38.204 [SPEAKER_01]: Maybe it is time to reduce your relax and maybe your IVs out, and it's not getting there. 33:38.264 --> 33:38.624 [SPEAKER_01]: Okay. 33:38.664 --> 33:40.804 [SPEAKER_01]: So I think first be open minded. 33:41.745 --> 33:46.606 [SPEAKER_01]: The days it's just being like shut up, surgeon, I think are gone and for good reason. 33:47.106 --> 33:48.166 [SPEAKER_01]: And so be open minded. 33:48.206 --> 33:49.607 [SPEAKER_01]: Maybe there's something you don't know here. 33:51.415 --> 33:52.196 [SPEAKER_01]: this isn't that. 33:53.216 --> 33:57.479 [SPEAKER_01]: I would say I just reduced the the the real accent. 33:57.499 --> 34:19.294 [SPEAKER_01]: It doesn't work right away I just want you to know that why don't we just wait a couple minutes and then you want me to ask you again and then that feels like they got something because a lot of this is that they need to feel that there's a transaction was made they're not yelling at you because they want you to be you to ignore them and they're certainly not yelling at you for a response back that's equally aggressive but they'll take it right 34:21.254 --> 34:29.276 [SPEAKER_01]: They're kind of saying something because they want to respond so they want to know that you're engaged in the same way that they are in the time to help them, let's say. 34:29.856 --> 34:37.578 [SPEAKER_01]: So I think create sort of boundaries that say, I just gave some, it doesn't work right away. 34:37.598 --> 34:42.180 [SPEAKER_01]: How about I check back in in two minutes when it will really take effect? 34:43.660 --> 34:47.341 [SPEAKER_01]: Is a lot better than saying, well I've got zero twitches on and I had to help you. 34:48.618 --> 34:53.619 [SPEAKER_01]: Because what it does is it makes a time-bound response, it could be completely artificial. 34:53.719 --> 34:56.380 [SPEAKER_01]: You could probably not have to reduce the rock uranium. 34:56.460 --> 35:02.981 [SPEAKER_01]: You could probably just in that time, check that your electrodes are on the right place, and you really do have zero twitches. 35:04.062 --> 35:05.642 [SPEAKER_01]: But it does give them something. 35:05.682 --> 35:09.343 [SPEAKER_01]: There is a transaction, you check back in, which shows that you care. 35:09.363 --> 35:13.984 [SPEAKER_01]: And sometimes that's all that it takes, is just to say, how's it now? 35:14.044 --> 35:14.604 [SPEAKER_01]: Is it better now? 35:18.652 --> 35:21.333 [SPEAKER_01]: that nine times out of ten, they're like, oh, it's so much better now. 35:21.834 --> 35:22.294 [SPEAKER_01]: What did you do? 35:22.334 --> 35:25.635 [SPEAKER_01]: You know, like, oh, I did exactly what you asked for, doctor. 35:26.256 --> 35:28.077 [SPEAKER_01]: Even if you did absolutely nothing. 35:28.137 --> 35:29.297 [SPEAKER_01]: Now again, it's cynical. 35:29.517 --> 35:30.698 [SPEAKER_01]: It is tactical empathy. 35:31.518 --> 35:37.041 [SPEAKER_01]: But you have to know that you're not necessarily dealing with the same person that you met preoperatively. 35:37.081 --> 35:38.682 [SPEAKER_01]: They might be really stressed out right now. 35:39.142 --> 35:42.584 [SPEAKER_01]: And so they're sort of not necessarily thinking about the the best 35:43.403 --> 35:45.204 [SPEAKER_01]: social interaction they could have. 35:45.384 --> 35:50.925 [SPEAKER_01]: And so you've got to just sort of like play into that as opposed to just putting up a wall and fighting them immediately. 35:51.386 --> 35:52.046 [SPEAKER_00]: Yeah, great. 35:52.226 --> 35:52.786 [SPEAKER_00]: I love that. 35:53.066 --> 35:59.028 [SPEAKER_00]: And I do think that that engagement that willingness to not rise to the bay not get really mad. 35:59.068 --> 36:00.869 [SPEAKER_00]: Just say, look, this isn't personal, right? 36:01.269 --> 36:04.570 [SPEAKER_00]: This is their their stress to clearly their stress about something. 36:04.610 --> 36:05.490 [SPEAKER_00]: Maybe they've got some bleeding. 36:05.550 --> 36:07.171 [SPEAKER_00]: Maybe they aren't getting where they need to get. 36:08.151 --> 36:10.874 [SPEAKER_00]: And this is how they're manifesting that stress. 36:10.934 --> 36:15.799 [SPEAKER_00]: It doesn't mean it's good, but it also doesn't mean that it's going to help if we kind of rise to that bait. 36:15.839 --> 36:21.684 [SPEAKER_00]: And so understanding that and then trying to have some sort of give and take, I'm happy to let me check again. 36:21.745 --> 36:25.789 [SPEAKER_00]: I just gave some rock or let me check in with you in two minutes when I know this is taken effect. 36:27.370 --> 36:51.505 [SPEAKER_00]: you know just giving them something and and even if you said before giving them an out I think in a way that's an out right is that I think sometimes surgeons will say something like that and they realize that it maybe wasn't very nice but they you know what are they going to do be like sorry I let me take back what I just said but if you say if you give them that out like what you know I just gave some let me let me just check twitches again and I'll check back in with you in two minutes it gives them a way to be like great and to not further pursue that 36:52.285 --> 37:00.070 [SPEAKER_00]: And I think it's a resident, if that doesn't work and they start getting more angry and aggressive at that's where I think you do need to you let your attending know and call for some help. 37:00.911 --> 37:06.795 [SPEAKER_01]: Absolutely, and certainly, you know, for many years, I worked with a wonderful surgeon who's 37:07.459 --> 37:26.451 [SPEAKER_01]: who was since passed away, and he was an old school guy and did old, you know, sinus surgery and the liberal hypotension was very important for Himo Stasis, and it was amazing that when I would leave the room immediately, he would say that the bleeding is uncontrollable, what are you doing? 37:26.471 --> 37:29.413 [SPEAKER_01]: And I would always tell the resident at the start of the day. 37:30.661 --> 37:44.803 [SPEAKER_01]: give him a couple of plans of attack and say, okay, I'm going up on X, Y and Z, even if the blood pressure is 40 over 20, tell him that you're starting, you know, obey the wall at, you know, 10 milligrams per second or something like that. 37:45.684 --> 37:51.965 [SPEAKER_01]: Even if that's not what you're doing, but just give him sort of like a step-wise progressions, say, okay, let me try this, let me try that. 37:52.765 --> 37:59.206 [SPEAKER_01]: And then if that doesn't work, just call me into the room and I'll pop back in, 37:59.983 --> 38:19.970 [SPEAKER_01]: and I'll tell him that we're putting the turnicator around the neck of what I always used to say to him and then he would say amazing you fixed it already and I would be there for like 20 seconds and some of it was just comfort level with that maybe junior resident or maybe the reaction he got didn't seem mature enough or something like that and so it was all a big 38:20.710 --> 38:30.538 [SPEAKER_01]: psychological undertaking and and look, I do think that you can walk away with a lot of this thinking ah, so resentful of the fact that I even have to play this game. 38:30.938 --> 38:34.581 [SPEAKER_01]: But all of your interactions with human beings are negotiations. 38:35.750 --> 38:42.314 [SPEAKER_01]: Whether those of your children who don't want to go to sleep yet and they want to stay up in the morning movie, or like I said, you're buying a car. 38:42.474 --> 38:43.814 [SPEAKER_01]: It's all in negotiation. 38:44.255 --> 38:44.995 [SPEAKER_01]: And that's okay. 38:45.035 --> 38:46.416 [SPEAKER_01]: You don't have to seek an apology. 38:46.916 --> 38:49.838 [SPEAKER_01]: You don't have to hope for a better situation. 38:50.938 --> 38:53.179 [SPEAKER_01]: It's just that you do have to know how to play the game. 38:54.180 --> 39:00.223 [SPEAKER_01]: And you can play it in a way where you make things better for the care that everyone is providing. 39:00.583 --> 39:03.805 [SPEAKER_01]: And ultimately, look, at least if you have to play a game. 39:04.598 --> 39:15.763 [SPEAKER_01]: At least you know it's been a fitting your patient and I would much rather do that than then to get into big arguments with people and the expats right or got from it do anything stupid in the operating room. 39:16.695 --> 39:22.977 [SPEAKER_01]: And then you know, then you just do a good job for the person that I'm tasked with caring for. 39:23.417 --> 39:23.797 [SPEAKER_00]: Absolutely. 39:24.177 --> 39:26.258 [SPEAKER_00]: Let's talk about the one I brought up before. 39:26.698 --> 39:31.299 [SPEAKER_00]: What if your resident is doing their pre-op discussion? 39:31.579 --> 39:34.020 [SPEAKER_00]: And they are literally mid-sentence. 39:34.520 --> 39:36.741 [SPEAKER_00]: And the attending surgeon walks into the pre-op bay. 39:37.636 --> 39:42.962 [SPEAKER_00]: and just start talking to the patient, just completely in a rub as if your residence not even there. 39:43.903 --> 39:47.086 [SPEAKER_00]: And again, you're not actually there, but you're in there on their shoulder. 39:47.106 --> 39:49.409 [SPEAKER_00]: What would you tell them to say in that moment or to do? 39:50.668 --> 40:12.083 [SPEAKER_01]: Yeah, I mean, that's a difficult one, and certainly happens, and I've seen it happen, I've had it happen to me, as an attending, working alone with the surgeon that I never met, I'll never forget that my instincts in that situation were probably wrong, because I definitely didn't like it and reacted. 40:12.803 --> 40:15.885 [SPEAKER_01]: As I say, I preach this stuff, but I'm as 40:18.676 --> 40:42.609 [SPEAKER_01]: as anyone else, what the best you can do in a situation like that is to re-establish civility in a way that, again, gives them an out, but sends a message very clearly, this isn't the game we're going to play, and so what I've done, again since I've been much more 40:47.927 --> 40:54.468 [SPEAKER_01]: is you actually say, oh, hello, after words, like, you know, you don't do an in front of the patient, obviously. 40:54.488 --> 41:11.051 [SPEAKER_01]: And you say, I've realized in the middle of the, my talk with, you know, the patient that you and I must not have ever met, which is why you've grabbed the chart for me, thinking maybe I was a student or something like that. 41:11.111 --> 41:13.852 [SPEAKER_01]: But on Sam on the anesthesiologist in the room, 41:15.200 --> 41:15.880 [SPEAKER_01]: Nice to meet you. 41:16.141 --> 41:27.525 [SPEAKER_01]: I'm sure that the order of things is usually this way where we introduce ourselves and then we see the patients, but I hope they're us to the day, that's the way we're going to sort of do things. 41:28.325 --> 41:37.348 [SPEAKER_01]: And you know, I did actually do that to a neurologist who I'd never met before, and she had kind of come in and interrupted me in the middle of. 41:38.137 --> 41:55.810 [SPEAKER_01]: a pre-op history, well, you know, my patient was setting up the room, um, and then I picked up her first item, I said, you know, normally the sequence of events is, you and I say hello to one another, we get to know each other, and I say hi, I'm Sam, and you say hi, I'm so and so. 41:55.930 --> 42:05.657 [SPEAKER_01]: Now, this person happens to be like an assistant professor of urology, like she was like very green, and I said, so I decided to do a little pull-to-rank, I said, normally I would 42:07.193 --> 42:14.334 [SPEAKER_01]: I'm one of the anesthesia vice chairs, um, great to meet you, um, but I realize I found how this went down today. 42:14.954 --> 42:21.936 [SPEAKER_01]: Um, so this is me starting over with you, um, so that we, the rest of the day goes really, really smoothly. 42:21.956 --> 42:27.497 [SPEAKER_01]: And I think she kind of understood that this was a tacit, like, hey, don't do that again. 42:27.517 --> 42:28.897 [SPEAKER_01]: Don't pull that kind of stuff. 42:29.337 --> 42:30.717 [SPEAKER_01]: It did not improve her behavior. 42:31.637 --> 42:32.177 [SPEAKER_01]: I will set. 42:32.738 --> 42:32.998 [SPEAKER_01]: But for 42:36.797 --> 42:47.182 [SPEAKER_01]: And, you know, again, we got through it as best as we really could, and again, sadly enough I do think this is what it's like to work in many operating rooms. 42:48.042 --> 42:50.924 [SPEAKER_01]: It's better than it probably was 30, 40 years ago. 42:51.644 --> 42:52.844 [SPEAKER_01]: It's not going to be perfect. 42:53.865 --> 43:03.289 [SPEAKER_01]: But we just do our best when as long as we're armed with the kind of things that we need to make the situation a little bit nicer for the person that we're caring for. 43:05.000 --> 43:12.747 [SPEAKER_00]: Yeah, I think this is a super hard one, and obviously you got the added, you've had the instability, and then you've got the patient sitting right there, right? 43:12.787 --> 43:15.450 [SPEAKER_00]: So that makes it really really hard. 43:15.990 --> 43:18.212 [SPEAKER_00]: I like your approach to kind of how to deal with it afterwards. 43:18.372 --> 43:23.197 [SPEAKER_00]: I think what you just described obviously works for you, because you're in with a junior ret. 43:23.837 --> 43:42.219 [SPEAKER_00]: with a junior surgeon when you're a more senior anesthesiologist, I think that what I have have suggested is to my residents, if this happens to them is in the moment, I think you could, and I'm interested to hear what you think about this, but I think that in the moment, in front of the patient, you definitely don't want to start a brawl, but I think you could say something like 43:43.178 --> 44:03.514 [SPEAKER_00]: Oh my goodness, it looks like you're certain, like the surgeons start stalking and you could then say, like essentially in a Rob back, but not to say, excuse me, you could interrupt to just say to the patient, oh my goodness, it looks like your surgeon is here, you know what, let's just really quick finish up our last few things and then I'm going to let you and him have, you know, have all the time you need. 44:04.214 --> 44:09.036 [SPEAKER_00]: And I think that is, I think that is probably acceptable to anyone. 44:09.056 --> 44:10.476 [SPEAKER_00]: It doesn't look bad to the patient. 44:10.496 --> 44:11.817 [SPEAKER_00]: It doesn't look like there's a conflict. 44:12.457 --> 44:22.381 [SPEAKER_00]: And I think with most surgeons, I mean, I want to believe this, and I hope it's true, that most of the time what has happened here is not that they walked in and said, oh, look, there's the anesthesia resident. 44:22.561 --> 44:23.581 [SPEAKER_00]: I don't care what they're doing. 44:23.741 --> 44:24.841 [SPEAKER_00]: I'm going to just interrupt them. 44:25.242 --> 44:28.903 [SPEAKER_00]: I think, and I'm not trying to justify this, but I think what probably happens is, 44:29.563 --> 44:51.627 [SPEAKER_00]: They literally aren't seeing you like they walk in and they've got a million things going on in their head and they walk in and they're just like all right I got it hey to the patient and they're not even paying attention to what's happening They may think you're the the loved one the partner right and I get it I get that doesn't really make sense because you're sitting there holding the chart But you know again, they're not sitting there evaluating this over a period of time They're just walking in and they probably are registering there. 44:51.647 --> 44:53.567 [SPEAKER_00]: Somebody sit over there Somebody standing over there. 44:53.607 --> 44:57.328 [SPEAKER_00]: Maybe that's the patients, you know significant other and so they just start talking 44:57.988 --> 45:06.554 [SPEAKER_00]: And I think for most of them, if you give them a little gentle reminder, like what I just laid out, they're going to be like, oh my goodness, yeah, please finish, right? 45:07.354 --> 45:21.064 [SPEAKER_00]: And the few exceptions, who might not, who might be like, sorry, like you're going to have to finish after I'm done, then I think that's, if I were the resident at that point, I would then say to my attending, hey, this just happened and then I said this and they were very rude about it and let let the attending handle it. 45:21.804 --> 45:23.786 [SPEAKER_01]: Yeah, I think that's totally reasonable. 45:23.806 --> 45:26.848 [SPEAKER_01]: I mean, the beauty about all of this stuff is that 45:27.786 --> 45:49.615 [SPEAKER_01]: There's a lot of gray area there, and certainly, you have to imagine the surgeon has a relationship with the patient that you don't have, they've seen them for, you know, days, weeks, months leading up to the surgery, they see each other and most times, you know, patients will sort of train their eyes towards the surgeon, what's the surgeon going to do at that point, not say hello, even though you're in the middle of your work. 45:50.398 --> 46:14.878 [SPEAKER_01]: your your history and so you do have to give them yourself right you do have to give them an out there as well you would probably do the same thing very different than stealing the chart from them or just like showing them down but I think many times the search and kind of comes in while your midstream and now they're chatting to the good surgeons the ones that you know sort of were blessed to work with regularly just go 46:15.680 --> 46:20.103 [SPEAKER_01]: I'm going to come back after, you know, he's done chatting with you or something like that. 46:20.123 --> 46:32.632 [SPEAKER_01]: But even if they don't, it's, again, if not the end of the world, you have to always check, as I say, your own arrogance to being offended and certainly give people a pass. 46:32.672 --> 46:41.538 [SPEAKER_01]: You know, the thing I always try to, especially when I speak with mixed audiences is I always try to 46:45.009 --> 46:51.394 [SPEAKER_01]: Is that, you know, we don't do ourselves a lot of favors because we often look like we don't care. 46:51.975 --> 46:53.416 [SPEAKER_01]: We're back there with our feet up. 46:54.837 --> 47:02.403 [SPEAKER_01]: And so many times it's, you know, again, not justifying, but many times they don't really think much of of the people in our specialty. 47:03.104 --> 47:04.545 [SPEAKER_01]: So you have to sort of. 47:06.083 --> 47:23.617 [SPEAKER_01]: shoulder all that individually many times, because maybe the last 20 anesthesia providers this person encountered like they didn't care and you could say whatever you want or she could say whatever they want in front of the patient and just push you out of the way, so just deal with everybody individually, most people. 47:24.688 --> 47:32.254 [SPEAKER_01]: Especially if after an interaction like that, you go up to them and just say, hey, I realize that when you came in, we hadn't really met yet. 47:32.595 --> 47:33.816 [SPEAKER_01]: I'm saying I'm nice to meet you. 47:33.876 --> 47:35.037 [SPEAKER_01]: We're working together today. 47:35.697 --> 47:42.883 [SPEAKER_01]: Most people are more than happy to have that conversation because they didn't even think that it was offensive to do what they did. 47:42.903 --> 47:46.906 [SPEAKER_01]: And for sure, it's not the end of the world if they did something like that. 47:46.966 --> 47:49.989 [SPEAKER_01]: But you don't want them to sort of make a pattern of 47:50.673 --> 47:51.854 [SPEAKER_01]: just missing you in general. 47:52.714 --> 48:00.880 [SPEAKER_01]: So if it feels like that's what was going on, then you probably have to just handle it a little bit differently because it was kind of giving them a chance. 48:01.781 --> 48:02.001 [SPEAKER_00]: Great. 48:02.181 --> 48:04.102 [SPEAKER_00]: So let's talk about the future. 48:04.322 --> 48:06.903 [SPEAKER_00]: How do we talk a lot about kind of like that individual? 48:06.963 --> 48:08.264 [SPEAKER_00]: How do you handle these individually? 48:08.344 --> 48:22.950 [SPEAKER_00]: And even what does, you know, how might you have like a coffee talk with a maybe a brilliant jerk who is causing problems, but how for for the long term, what does a, what does an institution do to become a truly civil institution? 48:23.330 --> 48:25.771 [SPEAKER_00]: How do we get to a truly civil healthcare culture? 48:26.531 --> 48:27.072 [SPEAKER_00]: What do we need to do? 48:31.581 --> 48:33.582 [SPEAKER_01]: lofty goal, I would say. 48:34.662 --> 48:46.445 [SPEAKER_01]: We're probably at a time in our arc of societal history, even where stability is at an all-time level. 48:47.065 --> 48:49.346 [SPEAKER_01]: We're sort of more polarized than we've ever been. 48:50.006 --> 48:54.947 [SPEAKER_01]: We're more convinced our opinions are the right opinions than we've ever been. 48:55.885 --> 49:00.647 [SPEAKER_01]: which I think actually travels in parallel to with the fact that we're seeing more work place to the other day. 49:00.847 --> 49:06.970 [SPEAKER_01]: And again, healthcare is probably one of the worst, but this is true and almost every other kind of work. 49:07.690 --> 49:08.651 [SPEAKER_01]: So how do we fix this? 49:09.431 --> 49:18.755 [SPEAKER_01]: I don't think you can do it without leadership at the hospital level believing that this is the right way to conduct ourselves. 49:18.916 --> 49:23.498 [SPEAKER_01]: I think we have to actually go back to really, really old principles that where we 49:24.923 --> 49:42.628 [SPEAKER_01]: our white coats meant something, where we felt like our oats really meant something, and where we truly believe that, you know, it's not just the patients are in an ATM machine that comes to the hospital, they are actually a human being with families and lives and work to get back to. 49:43.449 --> 49:50.511 [SPEAKER_01]: And so because of that, we have to put on this very, very real act for them, 49:55.157 --> 50:05.545 [SPEAKER_01]: that everybody that they're encountering today is on the same team and that we're all trying to get them over the finish line today in the safest way possible. 50:06.325 --> 50:20.355 [SPEAKER_01]: I'd say that's very, very lofty and very, very 30,000 foot and you've got to hope that your hospital administrators all believe in this and that they don't just say this person brings in 50 cabbages a month 50:23.698 --> 50:33.882 [SPEAKER_01]: Now, I think the way that we affect that change from the inside out as a specialty is we have a better sense of decorum. 50:34.002 --> 50:37.983 [SPEAKER_01]: We really start to believe that what we do is important, that we're not a service line. 50:39.111 --> 50:42.873 [SPEAKER_01]: Certainly in my department, you know, our possible president was our former chair. 50:43.553 --> 50:50.136 [SPEAKER_01]: So for us, we feel very, very empowered to be anesthesiologist, even if it's not always easy and every cluster. 50:51.416 --> 50:58.439 [SPEAKER_01]: And the way that you get that across is you don't just cooperate with your surgical colleagues. 50:59.500 --> 51:00.560 [SPEAKER_01]: You collaborate with them. 51:00.980 --> 51:04.562 [SPEAKER_01]: It's much harder to abuse people that are 51:05.847 --> 51:09.410 [SPEAKER_01]: Part of your tribe, you know, we talked about the tribe very briefly earlier. 51:09.611 --> 51:11.633 [SPEAKER_01]: We are very tribal as animals go. 51:11.653 --> 51:16.117 [SPEAKER_01]: There's a lot of us versus them that we do whenever we can do it. 51:16.618 --> 51:25.367 [SPEAKER_01]: Well, what if the us was just everybody who works in the operating room as opposed to anesthesia versus surgery, anesthesia versus nursing, nurses versus surgeons, 51:26.167 --> 51:30.829 [SPEAKER_01]: and collaborations the only way you do that and probably heard if you're not at the table you're on the menu. 51:31.809 --> 51:36.331 [SPEAKER_01]: So I always give the same example here, but I think it's important. 51:36.872 --> 51:45.475 [SPEAKER_01]: I've worked pretty consistently outside for the past 15 years on one particular floor with a pretty tight group of surgeons. 51:46.856 --> 51:50.978 [SPEAKER_01]: Probably 80% of my time has spent it there with those folks. 51:52.194 --> 52:00.204 [SPEAKER_01]: and every couple of years it's a big crisis that we've got to improve the on-time starts and we've got to improve the turnover and all this kind of stuff. 52:00.884 --> 52:02.807 [SPEAKER_01]: Now I don't really care because 52:03.775 --> 52:07.876 [SPEAKER_01]: You know, if it starts to date a five or it starts at eight o'clock, I'm probably going to be fine. 52:08.936 --> 52:12.237 [SPEAKER_01]: If the turnover's 30 minutes, or if it's 38 minutes, I don't really care. 52:13.237 --> 52:20.039 [SPEAKER_01]: But I show up to that meeting, and I show my outrage with that, and I see. 52:20.139 --> 52:25.960 [SPEAKER_01]: And we absolutely have to get into the rooms at eight o'clock, and so they know that I'm united with them. 52:26.792 --> 52:29.953 [SPEAKER_01]: that gives this sort of common enemy of inefficiency. 52:30.593 --> 52:35.815 [SPEAKER_01]: And we see each other as collaborators, and it's really, really hard to abuse collaborators. 52:37.796 --> 52:39.457 [SPEAKER_01]: And that's how you form the tribe with them. 52:39.477 --> 52:42.058 [SPEAKER_01]: You sit with them, join the communities that they're on. 52:42.878 --> 52:47.340 [SPEAKER_01]: You take up the problems that are there, that they see as just their problems, and no one's there to help them. 52:48.546 --> 52:50.307 [SPEAKER_01]: We live a very different life in anesthesia. 52:50.327 --> 52:53.631 [SPEAKER_01]: We show up into the room, we set up our equipment, and we're ready to go. 52:54.171 --> 52:54.712 [SPEAKER_01]: They show up. 52:54.772 --> 52:56.814 [SPEAKER_01]: They don't know what's come out of the box day to day. 52:56.994 --> 53:03.681 [SPEAKER_01]: And we would be super frustrated if every time we opened up the learning scope, the light failed. 53:04.021 --> 53:05.562 [SPEAKER_01]: But that happens to them all the time. 53:06.383 --> 53:08.485 [SPEAKER_01]: So try to make their problems, your problems. 53:08.606 --> 53:09.847 [SPEAKER_01]: Get on the same team with them. 53:09.867 --> 53:11.869 [SPEAKER_01]: Be good stewards of the operating room. 53:12.530 --> 53:20.195 [SPEAKER_01]: And I think we really at least in the OR can fix a lot of our cultural issues by just teeming up with our surgical colleagues as much as we can. 53:20.955 --> 53:23.016 [SPEAKER_00]: Yeah, yeah, I think that makes such a difference. 53:23.036 --> 53:33.422 [SPEAKER_00]: It's actually feel very lucky to work in the ICU as well as the OR because that is a great example of where the surgeons that I work with in the ICU, we talk all the time. 53:33.523 --> 53:37.165 [SPEAKER_00]: We're discussing patients, what do we want to do day to day over time? 53:37.845 --> 54:01.943 [SPEAKER_00]: and then when we're in the OR together we know each other there's mutual respect and so that makes those interactions a lot better now obviously not everyone works in the ICU but I think even little that you've brought some great ways you know whether it's joining committees whether it's you know going to join grand rounds and saying hello to some people you know there's lots of ways to build relationships I also think that even little saying hello in pre-op 54:02.943 --> 54:06.405 [SPEAKER_00]: I send an email the night before to every surgeon I'm working with the next day. 54:06.445 --> 54:12.527 [SPEAKER_00]: I've done that from the time I finished training and even that little thing Means that we've had a touch point. 54:12.547 --> 54:13.247 [SPEAKER_00]: We've touched base. 54:13.647 --> 54:18.929 [SPEAKER_00]: They've heard from me They know I've looked in the case that I care that I'm asking them some questions Introduce myself. 54:18.969 --> 54:23.651 [SPEAKER_00]: I always copy my resident on it and I say this is my resident Sam You know who's working with us tomorrow. 54:23.991 --> 54:28.133 [SPEAKER_00]: So the surgeon has their name and knows them and I think all that stuff can make a big difference to 54:30.510 --> 54:31.733 [SPEAKER_00]: for sure, for sure. 54:32.274 --> 54:34.218 [SPEAKER_00]: Well, Sam, we covered a lot of great stuff. 54:34.699 --> 54:36.784 [SPEAKER_00]: Anything that you want to add before we move on. 54:38.346 --> 54:39.907 [SPEAKER_01]: No, I really appreciate you having me. 54:39.927 --> 54:42.347 [SPEAKER_01]: I'm happy to talk about this topic endlessly, almost. 54:42.847 --> 54:43.307 [SPEAKER_00]: Awesome. 54:43.327 --> 54:45.468 [SPEAKER_00]: Well, I highly recommend people check out your book. 54:45.628 --> 54:46.108 [SPEAKER_00]: It's great. 54:46.148 --> 54:47.028 [SPEAKER_00]: It's easy to read. 54:47.128 --> 54:48.109 [SPEAKER_00]: It really flies by. 54:48.409 --> 54:56.911 [SPEAKER_00]: And you go in really, one thing I love is there's even some bonus chapters in there that that go into a lot of detail about some very much on the ground. 54:56.991 --> 55:02.272 [SPEAKER_00]: Things you can do as an individual as a team to start addressing things and making change. 55:02.373 --> 55:03.653 [SPEAKER_00]: And that's really, really high yield. 55:04.233 --> 55:06.956 [SPEAKER_00]: But let's move to the portion of our show where we make random recommendations. 55:07.117 --> 55:09.219 [SPEAKER_00]: Do you have something you'd recommend the audience check out for fun? 55:10.361 --> 55:10.581 [SPEAKER_01]: Sure. 55:10.621 --> 55:13.605 [SPEAKER_01]: I think I'll do one high ground and one low ground recommendations. 55:13.625 --> 55:14.746 [SPEAKER_01]: That's okay. 55:14.786 --> 55:15.187 [SPEAKER_00]: Absolutely. 55:16.032 --> 55:24.475 [SPEAKER_01]: The high-brow recommendation is, you know, I'm a big evolutionary biology nerd, it's like sort of my, it was probably my calling that I miss. 55:25.135 --> 55:39.100 [SPEAKER_01]: But I love all the books by Nick Lane and he recently published a book called Oxygen and it's just about how Oxygen on our planet drills our evolution and how it influences the way that we live and even the way that we buy. 55:39.120 --> 55:42.061 [SPEAKER_01]: And then my low-brow recommendation. 55:43.099 --> 55:50.081 [SPEAKER_01]: We'll be that my son is 13 and he and I recently started watching the worse possible movies that we could take for one another so. 55:51.077 --> 56:02.646 [SPEAKER_01]: I made him watch the movie Deep Blue Sea, which is like a really great shark movie with Samuel El Jackson and some other people and it's really really just like kind of an awful, awful movie. 56:03.067 --> 56:11.673 [SPEAKER_01]: And then he made me watch a movie he found called Bird Demic and I have to say it's the single worst movie I've ever seen but we were laughing the entire time. 56:12.474 --> 56:15.797 [SPEAKER_01]: So I highly, highly recommend that you should check yourself to Bird 56:16.397 --> 56:22.141 [SPEAKER_01]: I think it's on like I'm video right now or something like that and it was free, so you don't have to spend any money. 56:22.822 --> 56:23.442 [SPEAKER_00]: That's pretty funny. 56:23.662 --> 56:24.483 [SPEAKER_00]: Okay awesome. 56:24.743 --> 56:30.207 [SPEAKER_00]: I'm going to recommend a book I just read that my brother recommended to me called Small Mercy's by Dennis LeHane. 56:30.948 --> 56:32.509 [SPEAKER_00]: Really, really great book. 56:32.589 --> 56:39.494 [SPEAKER_00]: It's a historical novel set in South Boston at the time of integration in the 70s and 56:41.435 --> 56:59.362 [SPEAKER_00]: uh... it's also a kind of a murder mystery and it's really well done uh... very very interesting history and then just really kind of gripping uh... murder mystery so highly recommended small mercies by dentists laying all right so i'm thank you so much for coming on the show thanks so much for having that i really appreciate it 57:00.130 --> 57:02.471 [SPEAKER_00]: All right, hopefully you got as much out of that as I did. 57:02.911 --> 57:03.991 [SPEAKER_00]: That was really fantastic. 57:04.271 --> 57:05.372 [SPEAKER_00]: Let us know what you thought. 57:05.612 --> 57:09.093 [SPEAKER_00]: Go to the website,acrack.com where you can leave a comment. 57:09.493 --> 57:11.394 [SPEAKER_00]: Others can learn from what you have to say. 57:12.254 --> 57:15.235 [SPEAKER_00]: If you are a fan of the show, you can follow us. 57:15.555 --> 57:16.355 [SPEAKER_00]: We're on Twitter. 57:16.795 --> 57:18.056 [SPEAKER_00]: We are on Facebook. 57:18.516 --> 57:19.976 [SPEAKER_00]: We are on Reddit. 57:20.376 --> 57:21.457 [SPEAKER_00]: And we are an Instagram. 57:22.097 --> 57:23.658 [SPEAKER_00]: I'm at Jay Wolpa on Twitter. 57:23.738 --> 57:25.178 [SPEAKER_00]: And we're at Acrack Podcast. 57:25.478 --> 57:28.019 [SPEAKER_00]: And you can find us on all those other platforms as well. 57:28.459 --> 57:36.823 [SPEAKER_00]: If you are a fan of the show, please consider going to Apple Podcasts or wherever you get your podcasts and leaving a comment and a rating, it really helps others find the show. 57:37.263 --> 57:47.027 [SPEAKER_00]: If you'd like to support the making of the show, please consider going to patreon.com-acrack that's p-a-t-r-e-o-n.com-ac-r-ac where you can become a patron of the show. 57:47.707 --> 57:51.210 [SPEAKER_00]: Even if it's just $1 or 2 that you pledge, it makes a big difference and we really appreciate it. 57:51.610 --> 57:59.456 [SPEAKER_00]: You can also make donations anytime by going to PayPal.me-slash-acrack or looking up J.Wallpa on Venmo. 57:59.777 --> 58:04.420 [SPEAKER_00]: Thank you so much to those who have already made donations and become patrons, we really appreciate it. 58:04.881 --> 58:07.783 [SPEAKER_00]: Thanks as always to our fantastic acrack crew. 58:08.484 --> 58:16.150 [SPEAKER_00]: Sonia Aminat is our tech lead, Taylor Duggen, William Mao, and Rachel Furman are our production assistance and social media managers. 58:16.590 --> 58:17.951 [SPEAKER_00]: Thanks so much for all you do. 58:18.691 --> 58:21.432 [SPEAKER_00]: Our original ACRAG Music is by Dr. Dennis Quow. 58:21.792 --> 58:24.813 [SPEAKER_00]: You can check out his website at studymusicproject.com. 58:25.694 --> 58:29.856 [SPEAKER_00]: All right, that is it for today for the ACRAG podcast. 58:30.256 --> 58:31.156 [SPEAKER_00]: I'm Jed Wolpa. 58:31.676 --> 58:32.457 [SPEAKER_00]: Thanks for listening. 58:32.957 --> 58:38.099 [SPEAKER_00]: Remember what you're doing out there every day is really important and valued.