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Circle Up
5 Plays5 years ago
In this episode of Critical Matters, we will discuss innovation in care through the lens of process and workflow. Over the last several months, we have discussed new drugs, novel therapeutic approaches, and ventilator management strategies. However, the most vital source of innovation and success has been adapting to COVID-19 with new ICU workflows.
Our guest is Dr. Laura Rock, a pulmonary and critical care physician at Beth Israel Deaconess Medical Center in Boston. Dr. Rock is also faculty at Harvard Medical School, at the Center for Medical Simulation and is a trained Vital Talk instructor. She shares with us the concept of "Circle Up".
Additional Resources:
"Circle Up": Workflow Adaptation and Psychological Support via Briefing, Debriefing, and Peer Support: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0240
Emotions and COVID-19: GIVE to Connect, Understand, and Support: https://litfl.com/emotions-and-covid-19-give-to-connect-understand-and-support/
Don't Answer Feelings with Facts: https://blogs.bmj.com/bmj/2020/04/13/laura-k-rock-dont-answer-feelings-with-facts/
An excellent resource to learn more about "Circle Up": https://harvardmedsim.org/circleup/
VitalTalk - Resource for Patient/Family Communication: https://www.vitaltalk.org/resources/
Books Mentioned in this Episode:
In Shock by Rana Awdish: https://www.amazon.com/Shock-Journey-Death-Recovery-Redemptive/
What Doctors Feel by Daniel Ofri: https://www.amazon.com/What-Doctors-Feel/
Being Mortal by Atul Gawande: https://www.amazon.com/Being-Mortal-Medicine-What-Matters/
Humble Inquiry by Edgar Shein: https://www.amazon.com/Humble-Inquiry-Gentle-Instead-Telling/
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
00:00:20
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:27
Speaker
And now your host, Dr. Sergio Zanotti.
Dr. Lara Rock on Emotions in Critical Care
00:00:33
Speaker
The COVID-19 pandemic has impacted critical care teams all over the country.
00:00:37
Speaker
It has forced us to learn, adapt, and innovate at a breathtaking pace.
00:00:41
Speaker
Over the last several months, we have discussed new drugs, novel therapeutic approaches, and ventilator management strategies.
00:00:48
Speaker
However, the most vital source of innovation and success has been adapting to COVID-19 with new ICU workflows.
00:00:56
Speaker
In today's episode of the podcast, we will discuss innovation and care through the lens of process and workflow.
00:01:03
Speaker
Our guest is Dr. Lara Rock.
00:01:04
Speaker
Dr. Rock is a pulmonologist and critical care physician at the Beth Israel Deaconess Medical Center in Boston, Massachusetts, and an assistant professor at Harvard Medical School.
00:01:13
Speaker
She's also faculty for the Center for Medical Simulation and is trained as a vital talk instructor.
00:01:18
Speaker
Her areas of interest include how emotion impacts cognitive processes, debriefing clinical work, and how we teach and perform difficult conversations in critical care.
Innovation in ICU Workflow: CircleOps
00:01:28
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Today, she will discuss with us a workflow innovation called CircleOps.
00:01:32
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Laura, welcome to Critical Matters.
00:01:35
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Thank you.
00:01:35
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I'm happy to be here.
00:01:37
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I would like to start with a brief take on innovation.
00:01:43
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I find that most people, especially during COVID-19, when they think of innovation in medical practice, are thinking of new modes of ventilation, new antibody cocktails, novel drugs, a vaccine.
00:01:56
Speaker
Yet you are interested in study and apply other types of innovations that I think are much more pervasive
00:02:03
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and more important perhaps in our workflow.
00:02:05
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How do you view innovation in general?
00:02:08
Speaker
You know, I think I used to share that same bias that what I'm talking about or the work that I do isn't really that sexy compared to being an expert in ECMO or talking about ARDS and ventilator modalities.
00:02:22
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And ultimately I've realized that if we don't have an opportunity to reflect and improve what we do every day,
00:02:32
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then all of these other interventions really won't make much of an impact.
Lean Six Sigma Insights in ICU Rounding
00:02:37
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So I have absolutely been kind of blown away that in medicine, especially in a high stakes, incredibly fast and rapidly changing and evolving place like critical care that we don't naturally and routinely take the time to learn from our daily work.
00:02:59
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And I believe that that is something that a lot of clinicians fail to see at many points in their career.
00:03:06
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I remember that the aha moment came to me when I, being an attending, became a black belt in the Lean Six Sigma and asked the question, why do we round the way we round in the ICU?
00:03:19
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And the answer I would get most often is because that's the way we rounded before.
00:03:24
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And that's the way I was taught to round
00:03:26
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And it really struck me that a process that is so important for what we do on a daily basis hadn't been re-examined, at least where I was, in a long time.
00:03:36
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And we really didn't ask, how could we do this better?
00:03:38
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We do it every day.
00:03:40
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It impacts every patient.
00:03:41
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Shouldn't we be really thinking of how do we design this to achieve the goals we want in a better way?
00:03:47
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And how do we keep moving it forward?
00:03:50
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And I sense that a lot of what you study really falls in that category of innovation.
00:03:54
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Yeah, isn't that fascinating?
00:03:58
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I got really interested in debriefing for a few reasons.
00:04:02
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One was because I do a lot of work in simulation-based medical education and just my firsthand experience at seeing the impact of different professions sharing their perspective after a simulated crisis.
Clinical Debriefing for Improved Communication
00:04:17
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It was so impactful and I just thought we're really missing an opportunity if we're expecting every professional to go into a simulation and take a several hour long or day long simulation course because that's just not, we don't have the resources for that or the time.
00:04:34
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So we need to find a way to bring these opportunities for perspective sharing and learning into our clinical environments.
00:04:41
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And then I also had
00:04:43
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a few aha moments of realizing how debriefing could have changed the ability of people to work.
00:04:51
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So I was in a code a few years ago.
00:04:55
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I walked into a code where the anesthesiologist was telling a nurse to push epi, which was appropriate at that moment.
00:05:02
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And the nurse kept saying, well, we don't have a central line.
00:05:05
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And the anesthesiologist said, well, we don't need a central line.
00:05:09
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We have access.
00:05:10
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Push the epi.
00:05:11
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and the nurse was really hesitant and it actually delayed the epi for the patient and I threw in an IR and we moved everything to that so it sort of became mood and the patient survived so we really didn't, there wasn't really much of a discussion about that moment but I learned later from talking with the nurse and the doctor that a couple of years earlier that same nurse was with the same doctor and she pushed epi for a patient in which it was appropriate and the patient survived the code but lost her hand.
00:05:39
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because she had severe vascular disease.
00:05:42
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And she had never talked about it.
00:05:43
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And she had never really debriefed that experience.
00:05:46
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And so here she was, a very experienced and excellent critical care nurse, really unable to perform her job the way she had before because of her emotion around causing this patient harm, which she had taken personal responsibility for.
00:06:05
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And I think that there are a lot of situations like that where we just never really talk through something that happened or don't even really understand necessarily all the elements clinically or emotionally that sort of were involved in the experience.
00:06:21
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So we don't allow it to inform what we do next.
00:06:25
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And then there are a lot of situations where I think there's just a lot of confusion that we don't take the time to sort of unpack
00:06:32
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How was our communication affecting the experience for this patient?
00:06:37
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So one was kind of a silly experience where my mother was a patient and she had this huge chart.
00:06:43
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And on the top of the chart, there was a post-it that said, no type and screen.
00:06:47
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She was going in for surgery.
00:06:48
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And so she was in pre-op and this post-it said, no type and screen.
00:06:51
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And in the next hour, four different nurses and assistants came and brought the chart and said, oh,
00:06:59
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no type in screen, I guess we don't need one.
00:07:02
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I was going to draw blood, but I don't need to.
00:07:04
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And then the next person came and said, oh, it looks like there's no type in screen.
00:07:08
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I better draw this and put in an order.
00:07:11
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And then the next one thought it meant that my mother was refusing blood products.
00:07:14
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So I was there and I kept saying to the people, I really think you should check the chart or talk to your team because I don't think you're all on the same page about what that post-it means.
00:07:25
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And it just made it sort of remind me, like, we don't,
00:07:29
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routinely have these kinds of conversations to get on the same page.
00:07:33
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Yeah.
00:07:33
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And I think it speaks to that idea that it's not what we say, it's what people hear.
00:07:37
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So I guess it's not what we write, it's what people read.
00:07:40
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That was the case for your mom's chart.
00:07:42
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But it's a common example that I'm sure happens every day in hospitals across America and the world.
00:07:49
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Right.
00:07:49
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And what if she had an O-Type and Screen Ordered and she had a catastrophic bleed in the OR?
00:07:56
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and they had no blood for her.
00:07:57
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I mean, that didn't happen, but that it's a simple and very innocent mistake that could have been catastrophic.
00:08:06
Speaker
So we touched on two critical elements of high performing teams, and I wanted to dig a little bit deeper there.
Ensuring Psychological Safety in Teams
00:08:14
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And then one of the pieces that you wrote recently for Catalyst, I found a quote from another article that talks about holding ourselves to high standards while holding
00:08:25
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each other in high regard, but I think it really opens the door to what in my humble opinion is the most important aspects of great teams, which is psychological safety and communication.
00:08:38
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Can we dig a little bit deeper into psychological safety and what it means to you, what it means to a team, how you think about it in the ICU where teams are changing constantly?
00:08:49
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For example, you walk into a code, it's a different team every time there's a code.
00:08:54
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there's elements of our team that are the same, but the reality is that we're teaming up with people on a regular basis in the ICU.
00:09:01
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So how do you think about psychological safety and how it impacts the performance of that team?
00:09:07
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So I really learned a lot about psychological safety from reading Amy Edmondson, her work.
00:09:14
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She really popularized that term.
00:09:16
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I can't remember if she coined it, but she writes a lot about psychological safety.
00:09:20
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And I think the way she would define it as,
00:09:24
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is feeling that you won't feel humiliated or shamed for raising a concern that your perspective is valued and that there's an invitation to speak up and participate in the conversation.
00:09:41
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And I think that without that, we really are not able to tap into the strengths and skills of every team member.
00:09:52
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So, I mean, we know that speaking up is really hard and that, I mean, there's a lot of literature on speaking up and that sometimes even in a moment that could actually be life and death defining for a patient, subordinates will feel a lack of psychological safety and won't speak up even if they think they know something that could save the life of a patient because there's so much emotion around being wrong and feeling like, well, what if I,
00:10:22
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you know, what if I'm wrong?
00:10:23
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What if they probably already know what I was going to say?
00:10:26
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And so it's just fundamental to a team functioning well.
00:10:32
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And as you mentioned in the introduction, I have been teaching for Center for Medical Simulation since I participated in my first course with them over 10 years ago.
00:10:42
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And the work at that organization is really foundational in the way
00:10:50
Speaker
this pairing of curiosity and respect.
00:10:52
Speaker
So the idea is communicating, teaching, and learning from a stance of respect and curiosity, where you have high standards and you also have high regard for your learners and for your colleagues and for your patients.
00:11:07
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And I think that this concept was really transformative for me because I already felt
00:11:15
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really drawn to difficult conversations and building trust with patients and family.
00:11:21
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But ultimately, our patients and family members can't really trust us.
00:11:26
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We don't convey a sense of trust for each other.
00:11:30
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And so, I mean, I think we know that when a patient or family member senses conflict among the team, it's incredibly stressful for them.
00:11:38
Speaker
And when they feel a sense of mutual support and sort of a, you know,
00:11:44
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connection among the team, I think it really puts them at ease knowing that the team will communicate well to give them their best work.
00:11:52
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So to me, psychological safety for our learners, for our patients, but also for each other, it allows us to bring out our best work.
00:12:03
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And I think an important point, Laura, to emphasize is that, especially in ICU, but for any team, I believe this is true,
00:12:13
Speaker
that it's not only speaking up when perhaps there's a safety event about to occur, and the most dramatic example would be in the OR, which has happened historically multiple times, the surgeon's about to amputate the wrong leg, and nobody speaks up, right?
00:12:29
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That's like the extreme example.
00:12:32
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I also think it's about feeling comfortable and safe to just suggest an idea, no matter how stupid it might or might not be, it might work, and this applies specifically to COVID,
00:12:42
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somebody at one point said, why don't we put the IV poles outside of the room?
00:12:49
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And I'm sure a lot of people thought about that and didn't say anything because they didn't feel it would be safe to suggest that, but somebody suggested it, and then a lot of ICUs were doing that, and it just helped minimize the amount of entrances that the nurses had to that room, which may or may not be a good thing.
00:13:06
Speaker
We still don't know that, but just an example of how having that safety to speak up and share
00:13:12
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what might be an idea without feeling any repercussions is really important on both extremes when things are very stressful, but also when we're just trying to improve our daily work.
From Individual Resilience to Supportive Environments
00:13:24
Speaker
Absolutely.
00:13:24
Speaker
And I actually think another nice side effect of moving the IVs, the pumps, is that can you imagine being next to that loud beeping alarm every time there's a air bubble or the bag is empty and your patient trying to sleep or heal?
00:13:42
Speaker
But no, I think that that's absolutely right.
00:13:46
Speaker
And even if people don't like the idea, just saying, huh, I'm not, you know, I have reasons that I think that might not work, but I'm so glad you brought it up.
00:13:55
Speaker
It's such an interesting, you know, innovation.
00:13:59
Speaker
It'll encourage people to be willing to speak up the next time, even if you don't embrace their idea.
00:14:04
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So I think that
00:14:06
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It's the way we receive efforts to speak up that creates a culture of being willing to speak up.
00:14:12
Speaker
And the other part about it that's really fundamental is that it allows people to have some agency and participate in problem solving, which really gives people more of a sense of purpose in their work, which we know is fundamental to feeling joy.
00:14:27
Speaker
Yeah.
00:14:29
Speaker
It speaks to the idea of we manage people the best we can hope for is compliance, that we empower people.
00:14:35
Speaker
we can hope for engagement, which like you stated is I think the most important element to find joy in our work is to be engaged in what we're doing and making a difference for others.
00:14:47
Speaker
Could you comment a little bit on a psychological wellbeing, obviously related to this, but I think it's a little bit different in terms of what we mean by that.
00:14:56
Speaker
And I think it's an important principle since when we talk about circle up, there is a component of circle up that really focuses on this as well.
00:15:06
Speaker
Sure.
00:15:08
Speaker
I am glad you asked this because I think there's been so much emphasis in the medical and lay press about resilience.
00:15:15
Speaker
And if I read one more article about drinking kale milkshakes or doing yoga, I think I'm going to have to write an article about how our focus should not be on individual resilience, although all those things are lovely.
00:15:29
Speaker
And if you enjoy yoga and kale, then you should do those things.
00:15:32
Speaker
But there's too much emphasis on
00:15:36
Speaker
on the individual clinician being responsible for their wellness.
00:15:39
Speaker
And I think strategies that focus on the individual clinician are missing an opportunity and an obligation because we as an organization can change the environment and promote wellness by the way that we interact and value each member of the team.
00:15:57
Speaker
So culture centers around people and relationships and empowerment.
00:16:03
Speaker
And that really has nothing to do with putting this pressure on individuals to beef up their own resilience.
00:16:12
Speaker
And I think that the concept of burnout tends to focus too much blame on an individual and their personal qualities of grit and resilience instead of finding preventative methods and peer support that isn't relegated to fixing broken physicians, but rather
00:16:31
Speaker
is about how do we change our culture to promote wellness through the way we do our work.
00:16:38
Speaker
And I have found personally that especially during COVID that people who are closer to COVID are usually more resilient because they're forced to bound with others.
00:16:51
Speaker
But also more important, like you said, as a leader, but also as a team member, if you
00:16:59
Speaker
worry or if you do things to try to promote the well-being of others it has a magical effect on your own well-being and that's the secret sauce right when everybody's doing what they can to help each other all of a sudden everybody's feeling a lot better about the situation understands that they're in it together and it really creates a bonding that is is hard to see when things are are very quiet or going as usual but are very evident when you have a crisis
00:17:27
Speaker
Yeah, I think that's true.
00:17:28
Speaker
And I think it's easier to do than we think, but it's not, it isn't, it isn't a natural part of our culture or it hasn't been, you know, really incorporated into our cultures in our, in our units.
00:17:43
Speaker
The other component that I believe is essential for team functioning at a high level is communication.
00:17:51
Speaker
And a lot of people have studied this in different ways and
00:17:54
Speaker
We talked about Amy Edmondson's work on psychological safety, but also she has pointed out in medical teams, and this has been replicated by the MIT Media Lab, that it's not necessarily the content of the communication, but the form that people communicate is very important.
00:18:09
Speaker
And probably when it reflects an equal exchange between team members, probably it's a representation of psychological safety to some extent.
00:18:20
Speaker
But can you talk a little bit about communication in terms of form versus content
00:18:24
Speaker
and how that's important for teams?
00:18:28
Speaker
Yeah, I think that what we remember most when we have interactions is the way that we feel when we walk away.
00:18:36
Speaker
I mean, I think if you think back on the teachers that have made the biggest difference in your life or even relationships that you've had, I think that we remember less about the content and more about the interpersonal part of the interaction.
00:18:53
Speaker
I always try to teach my kids when they were younger, you can tell someone's a good friend by how you feel after you've been with them.
00:19:00
Speaker
And I think that we also, because of this sort of, I have this overriding principle of emotion before cognition.
00:19:09
Speaker
And I think when we're preoccupied in our brains about, should I trust this person?
00:19:16
Speaker
How does this person make me feel?
00:19:18
Speaker
Even if you're doing it unconsciously,
00:19:20
Speaker
it kind of minimizes your bandwidth for the cognitive portion of the conversation.
00:19:24
Speaker
So when you feel at ease and you feel welcomed and you feel that psychological safety of your opinion is valued, then it really kind of allows you to relax and participate more fully in what you're trying to do.
00:19:45
Speaker
I'm not sure if that answered your question.
00:19:47
Speaker
It is, and it's going in that direction.
00:19:49
Speaker
And I think it's going to be also important when we start talking about Circle Up and what we expect from the team in terms of communication.
00:19:57
Speaker
So this might be a perfect point to just ask you, what is Circle Up from a very high level?
Circle Up: Enhancing Team Dynamics in the ICU
00:20:04
Speaker
So Circle Up is a series of
00:20:09
Speaker
interactions team-based interactions that provides a framework for regular time a regular time in place for problem solving and connection and um this started with um a pilot study at least for me it started with a pilot study last year where we um we did daily debriefings in one of our icus um and it was funded by crico we did a 10-minute debrief at the end of every shift for six weeks and
00:20:39
Speaker
That obviously was pre-COVID.
00:20:42
Speaker
And then when we started working in the COVID era, a bunch of us through Center for Medical Simulation and other affiliated groups put together this process of a briefing at the beginning of a shift, check-ins throughout the day, and a debriefing at the end of a shift, which are all very brief interactions, but really change a culture and provide a framework
00:21:06
Speaker
for this combination of problem solving and connection.
00:21:10
Speaker
And so it makes these interactions that are so fundamental to changing culture and to bringing out our best a regular part of the day.
00:21:20
Speaker
And where does the name come from?
00:21:23
Speaker
Seems like a sports analogy.
00:21:26
Speaker
Yeah, it is.
00:21:26
Speaker
I mean, I found myself using the term circle up just when I wanted the
00:21:31
Speaker
group when I wanted the team to just come together for a few minutes I'd say hey everybody circle up and actually I think our from our group Chris Reuson who's the senior author on that paper I think he is the one who applied it to this framework but it is meant to it is meant to invoke sort of a team huddle
00:21:55
Speaker
And it's kind of a pep talk and a brief meeting to coordinate plans to connect and kind of inspire for the shift and also offer an opportunity to reflect.
00:22:06
Speaker
And I also like that the name literally promotes forming a circle because I can talk about some of the elements that I think make these interactions most successful.
00:22:18
Speaker
But one is that you can literally see each other
00:22:21
Speaker
and hear each other, which I think is often not the case in a large ICU where there's a lot of ambient noise and people are on computers and some people are sitting and some people are standing.
00:22:33
Speaker
And so I think it doesn't literally have to be a perfect circle, but creating a physical connection that allows for this sort of emotional connection and logistical connection of talking through
00:22:50
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work and solving problems together.
00:22:53
Speaker
Before we dive into the framework and the specific components and best practices, how does Circle Up differ?
00:23:02
Speaker
How is it different from ICU rounds, for example?
00:23:06
Speaker
So, I mean, there are a lot of regular team conversations that we could compare this with.
00:23:14
Speaker
So team rounds, at least in our institutions, usually involves the
00:23:21
Speaker
medical staff, so the attending physician and if we have fellows and residents, being there for the entire round, you know, rounds experience, which often lasts for several hours.
00:23:33
Speaker
And the nurses come in and out depending on whether we, you know, which patient we're discussing.
00:23:38
Speaker
We are also often joined by pharmacy and respiratory therapy come in and out depending on, you know, if it's relevant for that patient.
00:23:48
Speaker
But rounds is a conversation about patients.
00:23:50
Speaker
We're trying to coordinate the care for that patient for the day.
00:23:54
Speaker
We also have other team-oriented conversations, like in our institution, we have a morning huddle where we, in 10 minutes, quickly go through sort of an overview of the unit, which patients are going to be leaving for procedures, which patients need physical therapy or social work or case management.
00:24:13
Speaker
But the main difference is that those are conversations about patients.
00:24:17
Speaker
The circle of conversations are largely about the team itself.
00:24:21
Speaker
And I think this is what makes it novel.
00:24:26
Speaker
We're promoting a conversation that's really about having the team connect with one another and the team to make plans together, anticipate challenges together, and then at the end of the day, to reflect together and sort of
00:24:42
Speaker
possibly have a giant exhale together after a tough day.
00:24:46
Speaker
So it's really a shift from only needing to talk about patients to actually talking about their own interactions, their own feelings, their own experience of the day and where they did well and where they see opportunities for improvement.
00:25:02
Speaker
We also have a lot of conversations obviously among different professions sort of in silos.
00:25:09
Speaker
So nurses may talk to one another about
00:25:13
Speaker
areas of improvement or things that they're frustrated by, but those might not get communicated to the entire team.
00:25:19
Speaker
They might have ideas for implementation that never really get heard by everyone else.
00:25:25
Speaker
And similarly, doctors have a lot of conferences and may have M&Ms that, I mean, in our institution, nurses do come to our critical care M&Ms, but not that many nurses.
00:25:35
Speaker
It's usually the leadership.
00:25:37
Speaker
So I think we're having a lot of siloed conversations
00:25:40
Speaker
The point of Circle Up is this is an interprofessional, interdisciplinary conversation that includes everyone working together to offer care for our patients.
00:25:52
Speaker
And when I say everyone, I mean including the secretary or unit coordinator, the chaplain if they're around,
00:26:01
Speaker
Sometimes, I mean, I can give you one really beautiful example of we were starting a circle up briefing in the beginning of a shift during our COVID surge in the spring and the housekeeper happened to be behind me emptying the trash.
00:26:14
Speaker
And I said, hey, why don't you join our conversation?
00:26:18
Speaker
And I said, I realized I've seen you here for the last several months and I don't know your name.
00:26:23
Speaker
And she told me her name, it's Tee Roo.
00:26:26
Speaker
And everyone on the team
00:26:29
Speaker
Fully turned around and gave her standing ovation and said we couldn't do any of this without you and You know it was really beautiful moment to have everyone come together and Appreciate, you know the work of someone who doesn't normally necessarily get noticed or appreciated So it's really not about patience and I can talk about how to be more efficient the morning briefing or the morning huddle can be sort of
00:26:57
Speaker
merged so that you aren't adding an extra meeting onto a busy workday.
00:27:02
Speaker
But for the most part, the focus of these conversations is about the team.
00:27:07
Speaker
That is a great distinction in terms of this is about the team and how the team functions and how the team is doing as opposed to individual patients.
00:27:17
Speaker
And that would be a big difference with ICU rounds.
00:27:20
Speaker
And like you mentioned with sign out, that might be physician to physician or nurse to nurse.
00:27:27
Speaker
The circle up, once again, is not about that individual patient, but about the team, but also has a much more multidisciplinary nature.
00:27:33
Speaker
And it seems that the circle up is even broader in its representation of who works in the ICU than ICU rounds.
00:27:40
Speaker
ICU rounds, at least in our programs, have become very, very multidisciplinary and more and more disciplines seem to be joining as we move forward, including families when they were allowed in the units.
00:27:53
Speaker
But this really is more about the team
00:27:56
Speaker
and having everybody who's working there.
00:27:57
Speaker
So that is a great, I think, point to emphasize.
00:28:02
Speaker
So tell us a little bit about the framework.
00:28:04
Speaker
What are the main elements?
00:28:05
Speaker
And then maybe we can dive into each one of those elements in a little bit more detail.
00:28:11
Speaker
Sure.
00:28:11
Speaker
So there are three main activities, briefing, peer check-ins, and debriefings.
00:28:18
Speaker
The briefing is,
00:28:21
Speaker
is really an opportunity to connect, to literally see who you're working with that day.
00:28:28
Speaker
In a busy ICU, you might actually have people on your team that you've never met before.
00:28:34
Speaker
It sets a tone for the shift.
00:28:36
Speaker
It's an opportunity to coordinate care and have a sort of team situational overview for the day.
00:28:43
Speaker
And would you like me to kind of give an example of how it might sound?
00:28:49
Speaker
Yeah, please, please.
00:28:51
Speaker
So I always start with introductions partly because I'm terrible with names and I think that there's always somebody that if you just say, does everybody know each other, then everyone will kind of nod and actually once again feel uncomfortable speaking up because they might not know the name of the respiratory therapist who's been working next to them for a year and they feel like it's too embarrassing to admit that.
00:29:12
Speaker
So it starts with, hey everybody, let's just take a few minutes to connect for the shift.
00:29:20
Speaker
I'm Laura, I'm going to be sort of leading this brief conversation.
00:29:24
Speaker
It doesn't have to be me.
00:29:25
Speaker
It doesn't have to be a doctor.
00:29:27
Speaker
It could be anyone on the team that's comfortable in that role.
00:29:31
Speaker
And then everybody says their name.
00:29:32
Speaker
And then during COVID, people would often say where they normally work because people were pulled to the unit who don't normally work in a unit.
00:29:39
Speaker
So I think that helped people know one another and feel a little bit like they could sort of say out loud that they're not used to being in the ICU.
00:29:48
Speaker
And I think, you know, it doesn't take long.
00:29:51
Speaker
And then sort of an invitation to speak up throughout the day.
00:29:54
Speaker
So we'd be like, we really want to hear from you.
00:29:56
Speaker
If you notice anything or if you're concerned, please let us, let me know or let, you know, someone else know who can share it with the group.
00:30:04
Speaker
Quick updates.
00:30:05
Speaker
So just so everybody knows, we have new ventilators today, but they're old ones.
00:30:11
Speaker
You're not used to seeing this dial on the side where the oxygen level is actually kind of hard to read.
00:30:18
Speaker
So we're just going to,
00:30:19
Speaker
quickly review like where you can read that.
00:30:22
Speaker
So it might be an update like that or it might be, you know, we have, you know, we only have two respiratory therapists today because somebody called out sick, so this is how we're gonna adapt.
00:30:35
Speaker
I might raise some concerns or I can ask the group, have you heard, you know, anything you wanna share with the group about any anticipated challenges today?
00:30:45
Speaker
And then an encouragement to support one another.
00:30:50
Speaker
Hey, this work is hard.
00:30:53
Speaker
Please just let me know or talk to someone you trust if you're having a tough day or if you just need a break.
00:31:02
Speaker
We really want to support each other.
00:31:04
Speaker
And I would often, especially during the COVID surge, I'd say I really want to remind you that you cannot go in to help a patient without proper PPE.
00:31:13
Speaker
So even if a patient disconnects from their ventilator, you cannot go into the room until you protect yourself.
00:31:18
Speaker
I know that it's not your identity, it's not your nature, but you have to protect yourself so you can continue to protect and save others.
00:31:26
Speaker
And I said that every day because I think that's such an important, you know, it's such an important thing to reinforce because it's just not, you know, we all have this identity of like everything for the patient.
00:31:37
Speaker
So it's that kind of thing that, you know, the whole conversation would just be like,
00:31:42
Speaker
sometimes five minutes.
00:31:44
Speaker
And if we wanted to pair it with a morning huddle where we would quickly review the needs for each patient for that day, it would probably be more like 10 or 15 minutes, but it was pretty short.
00:31:55
Speaker
And that is a very important point because every provider where they, a bedside provider where the physician and APP, a nurse and RT feels that their day is already flooded with shallow work that takes them away from
00:32:12
Speaker
the patient and every time you introduce something new, people roll their eyes because they just think it's another click on the EMR or another meeting I have to be and just adds to my daily work.
00:32:24
Speaker
But this can be done in a very short period of time.
00:32:27
Speaker
It can be incorporated and we'll talk about that a bit later into what we do on a regular basis.
00:32:31
Speaker
But what done systematically, as you'll share with us later, can have quite profound results on the team and that really is the message.
00:32:40
Speaker
Yeah, I mean, even in a short time, I will tell you later, like even in a short time, we had pretty profound, even clinical outcomes.
00:32:49
Speaker
But even immediately, I mean, people told me, I mean, they loved it.
00:32:53
Speaker
And nurses who were on units where they weren't doing this asked if they could start doing it.
00:32:57
Speaker
And it became like the nurses actually started doing it on weekends, even, you know, because we didn't include weekends in our study.
00:33:03
Speaker
They just really appreciated the connection.
00:33:06
Speaker
Nice.
00:33:09
Speaker
And briefing also can be a circle up prior to a procedure.
00:33:14
Speaker
If you're going to intubate a COVID-19 patient, especially at the beginning, I think a lot of teams recognize that having a briefing up front and discussing the plan, roles, questions, reminding people about proper PPE was probably a good idea.
00:33:29
Speaker
So it doesn't only have to be at the beginning of the shift, but clearly from the circle up concept, it's setting the tone and starting the shift.
00:33:37
Speaker
on the right track.
00:33:39
Speaker
So what's the second component?
00:33:41
Speaker
It's peer support, right?
00:33:43
Speaker
The second component is about peer check-in.
00:33:45
Speaker
So this is really an unscheduled reminder to check in with the people that are on your team.
Peer Support and the GIVE Framework in Healthcare
00:33:55
Speaker
Some people really don't need this reminder.
00:33:57
Speaker
I mean, our nursing director at the MICU at BIDMC, Kristen Russell, she's just one of these people that loses
00:34:07
Speaker
incredible competence and approachability and compassion.
00:34:10
Speaker
And I think, you know, she doesn't need to read this article.
00:34:14
Speaker
A lot of people I think do naturally create such a sense of psychological safety and approachability that they might not need this framework.
00:34:24
Speaker
But I think for a lot of people, especially if they're used to more technical, more kind of intervention oriented and sort of less communal atmosphere,
00:34:34
Speaker
it's an incredibly important reminder to check in with each person.
00:34:38
Speaker
We know from research on peer support, particularly by Joe Shapiro, that clinicians who are hurting would rather talk to their colleagues than to health professionals.
00:34:51
Speaker
And research on burnout and even severe mental health and suicidality shows that when
00:35:01
Speaker
mental health interventions, burnout interventions are offered, a significant percentage, over 40% of people who are suffering won't take advantage of them.
00:35:12
Speaker
So again, I think rather than pushing the onus onto individuals to seek and get their own help or to sort of work on their own individual resilience or burnout issues, when we create a culture that is about
00:35:30
Speaker
you know, a community that creates a community that makes it okay to have emotions, to make it okay to need to check in or take a quick break, we're going to create an environment where we can identify the people that may need help that we might not even know about, and we're going to hopefully provide an environment where we can offer that support to one another.
00:35:55
Speaker
I mean, I also think that, you know, if you check in with people emotionally,
00:35:59
Speaker
they're also going to be more likely to speak up about other things.
00:36:02
Speaker
So, you know, if you can't say to the team, you know, I'm really struggling today because my cat died and I'm really distracted and preoccupied, then you may not, you also may not, you know, be willing to say, I can't remember if I gave this patient's medication or not.
00:36:20
Speaker
Can you help me like check through my steps because I am just a little distracted today.
00:36:25
Speaker
I mean, so I think it's sort of,
00:36:28
Speaker
We're not promoting patient safety and isolation.
00:36:34
Speaker
We're thinking about humans who have human flaws.
00:36:38
Speaker
And so when we offer the kind of support and a framework that allows people to be human, then we can, again, bring out our best work.
00:36:53
Speaker
I believe also that an important aspect to talk about these micro check-ins is that people sometimes confuse being deliberate with not being authentic.
00:37:06
Speaker
And that seems to be a barrier for a lot of people to trying to do things that they don't usually do.
00:37:11
Speaker
I believe that you can be very authentic and be deliberate about saying, I'm going to ask several people today how they're doing and how I can support them.
00:37:21
Speaker
And once you establish that routine over several days, it becomes second nature and it's something that you just do.
00:37:28
Speaker
Could you talk a little bit about how you would encourage somebody who's never done one of these micro check-ins, new attending, who's trying to be a better team member, how would you counsel them in terms of this is what you should do today to support your peers?
00:37:44
Speaker
Yeah, well, first I want to make a comment about authenticity.
00:37:48
Speaker
You know, if you don't actually care about people, then you, you know, circle up is not going to work for you.
00:37:54
Speaker
You actually have to care and you, you can't fake caring.
00:37:59
Speaker
I don't think you can fake empathy and you might be able to learn some steps to make you, you know, you look empathic, but I think, you know, you, you actually have to care and be curious to, to,
00:38:10
Speaker
create an environment of caring and mutual support and curiosity.
00:38:15
Speaker
So assuming that you have that and it's not your nature to do these sort of interpersonal check-ins, first of all, I'm a big fan of just being really transparent and I'm a pretty casual person.
00:38:29
Speaker
So if that were me, I'd probably say, you know what, I'm trying a new thing.
00:38:34
Speaker
It's not really my, you know, it's not, I feel a little awkward doing this, but so bear with me.
00:38:40
Speaker
I might come by and just check in with you today and say, how's it going?
00:38:44
Speaker
So I would probably be upfront about that.
00:38:50
Speaker
Maybe that's too much of a stretch.
00:38:52
Speaker
If you're not comfortable doing it, maybe you're also not comfortable saying that out loud.
00:38:57
Speaker
But I think it has to be your style.
00:39:00
Speaker
It has to be something that you are comfortable with or it won't work.
00:39:03
Speaker
So I do think that you can take these concepts and think about, well, what am I comfortable with?
00:39:10
Speaker
And if it's really awkward for you, then maybe you should, and you care about it, you could delegate it to someone who does feel comfortable checking in.
00:39:19
Speaker
And that doesn't mean you don't care.
00:39:20
Speaker
It just maybe, you know, maybe it just means that you might not be the most approachable person or that it's, you know, it's something that you're working towards as opposed to feeling like you have to take on this whole framework in one day.
00:39:33
Speaker
But I think that sometimes the biggest barrier is just getting started and, you know,
00:39:38
Speaker
And doing it.
00:39:39
Speaker
And once you do it, you find out your style, but you also find that it has tremendous value for the team, for yourself and can make a true difference.
00:39:48
Speaker
I'm also, I'm also a big believer in redos.
00:39:51
Speaker
Like if you're, if you're the boss and you, you know, go around to the, you know, to the team at some point during the day and say, Hey, I'm checking in.
00:39:59
Speaker
And they say, I can't take, you know, one more family member screaming at me.
00:40:05
Speaker
And you say,
00:40:06
Speaker
oh, you're great, you'll be fine, you always rise to the top.
00:40:11
Speaker
And then you realize that is a non-answer, that is not supportive, that is not really allowing them to have the emotion they express.
00:40:20
Speaker
You can say, hey, you know what, I'm not sure I like the way I said that.
00:40:26
Speaker
That sounds really tough.
00:40:28
Speaker
Can you tell me what's going on?
00:40:30
Speaker
Do you wanna talk about it?
00:40:31
Speaker
Or, you know,
00:40:36
Speaker
I mean, so it's okay to realize that you don't have the perfect answer or the perfect response and to just kind of laugh at yourself and try it a different way.
00:40:46
Speaker
It's demonstrating vulnerability and humility.
00:40:50
Speaker
I want to go on a little bit of a, it's not really a tangent, but a different direction within this peer support component based on something that I read that you wrote that really highlighted something that I frequently do.
00:41:06
Speaker
which is I respond to emotion with facts.
00:41:10
Speaker
And my kids have been very prominent in pointing that out to me, but also I do it at work.
00:41:18
Speaker
And could you talk a little bit about that and the give framework and how you can use that when somebody says something that's really emotional to you and what's the best way to think or respond to that?
00:41:30
Speaker
Sure.
00:41:31
Speaker
So I learned a lot about,
00:41:36
Speaker
responding to emotion from the VitalTalk organization.
00:41:43
Speaker
I'm a VitalTalk instructor and Bob Arnold was a mentor of mine.
00:41:47
Speaker
So a lot of my thinking about this came from Bob Arnold and Tony Back and their faculty.
00:41:55
Speaker
And so the concept of don't answer feelings with facts is, I think this is really true for all of us.
00:42:02
Speaker
And even though I wrote that article, sometimes I still have to remind myself
00:42:06
Speaker
So it's really hard to do.
00:42:08
Speaker
It's very simple, but it's not that easy to do.
00:42:10
Speaker
And the idea of give is it's a mnemonic.
00:42:14
Speaker
And actually, I normally hate mnemonics because I don't remember what they stand for.
00:42:17
Speaker
But I like mine because I think if you don't remember what it stands for and all you remember is that when you encounter emotion, you should give.
00:42:26
Speaker
That's probably enough because the idea is just giving over to the emotion that's present and not feeling like you should provide information or fix the emotion.
00:42:36
Speaker
So I think as doctors, we like to fix things and we like to solve problems and we do that with emotion too.
00:42:43
Speaker
So a typical response to an expression of emotion, especially if it's subtle, is to provide information.
00:42:52
Speaker
So it might sound something like this.
00:42:57
Speaker
Well, what do you mean that antibiotics aren't working?
00:43:00
Speaker
Just, you have to have a solution.
00:43:03
Speaker
The sepsis has to get better.
00:43:06
Speaker
just change antibiotics.
00:43:08
Speaker
And the answering feelings with Fats response would be, well, we had an ID consult and they did all the sensitivities and we know the antibiotic was right, but sorry, it's just, it's not working.
00:43:22
Speaker
Or maybe an example that comes closer to home would be like, mom, I'm not going to school today, I have no friends.
00:43:30
Speaker
Well, of course you have friends, you were just invited to Sally's birthday party.
00:43:35
Speaker
You know, those are false reassurance.
00:43:38
Speaker
They're not, well, the first one isn't false reassurance, it's just information, but they're really not sort of acknowledging the emotion that's present, validating that the emotion is, you know, allowed and that it's normal and that, you know, it's okay to have emotion and then possibly aligning or, you know, supporting or exploring the emotion to understand it better.
00:44:02
Speaker
So, and this happened, I wrote another blog about answering feelings with FAPS or how to respond to emotion in COVID, which I can share with you, which was on the Life in the FAPS Land blog.
00:44:15
Speaker
And it sort of used examples of like, what do you mean I can't come see my dad?
00:44:20
Speaker
I want to talk to your supervisor.
00:44:21
Speaker
So the, you know, answering feelings with FAPS would be like, well, you can talk to my supervisor, but it's not going to make a difference as opposed to,
00:44:30
Speaker
this is really awful.
00:44:32
Speaker
I actually think this is the hardest part of all the care that we do.
00:44:36
Speaker
And I wish so badly you could come in and I would be so, I wouldn't even know how to deal with not being able to come see my family.
00:44:46
Speaker
And let's talk about maybe some things that we can do or help me understand
00:44:54
Speaker
how I can provide some connection for you even if you can't come in or something like that.
00:44:58
Speaker
So the steps are, the G is get that the emotion is present and that it's really important and why.
00:45:06
Speaker
Identify what behaviors you're seeing that suggest the emotion or if it seems appropriate, you can even identify it and say it out loud.
00:45:14
Speaker
So it might be something like, I'm noticing you're quieter than usual, what's going on or
00:45:20
Speaker
I can see that you're really frustrated.
00:45:23
Speaker
So it depends, you have to use your judgment.
00:45:25
Speaker
The V is validating and the E is exploring by often using the phrase, tell me more, but it could be, you know, tell me what's scaring me the most or whatever they shared that their emotion is.
00:45:43
Speaker
So it's just a short, but not that easy to do tool for,
00:45:50
Speaker
how to respond to emotion when it's present.
00:45:54
Speaker
And the way I understood when I read your blog and when I was reflecting on this is just a reminder that we always, especially as we get older and either as parents or as leaders, we are very quick to give people suggestions either of why their predicament is not so bad or what they can do about it.
00:46:13
Speaker
And maybe we should just stop and be more curious and understanding a little bit more
00:46:19
Speaker
about why they're feeling that way and how they're feeling that way before we even get to any solutions.
00:46:25
Speaker
And I would imagine that in these micro check-ins, a lot of times we won't have solution and it's just the acknowledgement and support that really matters.
00:46:35
Speaker
Yeah, and if you look in the vital talk work, they would argue that when you respond to the emotion, often people don't even want the answer to the original question.
00:46:44
Speaker
So, I mean, this might be an extreme example, but if someone says, is he gonna die?
00:46:50
Speaker
you know, that may be an information seeking question, but it's often an expression of a fear or some other emotion.
00:46:57
Speaker
So they would argue that if you say, this is really overwhelming and scary, you know, you've been through so much and I can understand feeling really terrified, you know, tell me what's scaring me the most and like talking through it, then it may not be actually that they're seeking an answer to that exact question, although
00:47:20
Speaker
you know, they still might want an answer and the information is also helpful, but they, you know, I learned a lot about this, this concept from them.
00:47:29
Speaker
Excellent.
00:47:30
Speaker
So we started the shift with the briefing.
00:47:34
Speaker
We have been working throughout the shift and checking on our, on the nurses, on the RTs and our colleagues doing some micro check-ins, really trying to, to, to understand how they're feeling, what are their challenges, how we can be supportive, listening.
00:47:50
Speaker
Tell us about the third component at the end of the day, the debriefing.
Impact of Circle Up on Team Dynamics
00:47:54
Speaker
Yeah, I guess, you know, the debriefing sort of my, maybe my little favorite part, which is just that, you know, I really like that the main emphasis of the debriefing is reflection.
00:48:05
Speaker
And, and I guess since that's what I started with, I sort of feel maybe most enthusiastic about that step because I feel like it provides such an important connection at the end of a day.
00:48:20
Speaker
So when we did this last year in our pilot, we kept it fairly unscripted.
00:48:26
Speaker
Initially when I wrote it, I had all these different steps to include related to care and patient safety and the patient experience and the family experience.
00:48:35
Speaker
And ultimately we just wanted it to be a conversation guided by the people on the team.
00:48:41
Speaker
So it always starts with introductions and just a quick reading
00:48:50
Speaker
And once a week, we actually, at the beginning of the week, we would start with reading the basic assumption, which is sort of a fundamental philosophy promoted by the Center for Medical Simulation, which is basically, I'm actually, I don't have it right in front of me, but it's basically, we believe that everyone working on this team wants to do their best, wants to provide the best possible care for patients and wants to improve.
00:49:20
Speaker
And the reason why I would read that out loud actually wasn't me.
00:49:23
Speaker
It was the debriefing leader, which was our critical care social worker.
00:49:27
Speaker
They would start the week that way by saying, you know, this it's, it's a way of saying this conversation isn't about blaming anybody or it's not about trying to be perfect.
00:49:38
Speaker
It's really, you know, a recognition that we all want the same thing, which is the best care for our patients and caring for one another and to bring out our best.
00:49:47
Speaker
So that's why we're doing this conversation.
00:49:49
Speaker
And then,
00:49:51
Speaker
Then we would say just, it would start with, hey, reactions to today.
00:49:57
Speaker
And then we had a few questions that could trigger a conversation that in case people weren't really naturally talking much on their own, which might be, what helped your team work well together today?
00:50:11
Speaker
How could our work be 1% better?
00:50:13
Speaker
And then how did the shift affect you personally?
00:50:17
Speaker
But usually they just talked.
00:50:20
Speaker
you know, on their own.
00:50:21
Speaker
And so I think just offering a space to have reactions, really people will talk.
00:50:28
Speaker
And once, you know, once they kind of get in the habit, they'll bring up what's on their mind.
00:50:35
Speaker
And it could be clinical things, it could be emotional things, but people did end up talking easily.
00:50:44
Speaker
Some, you know, some days it was a very short conversation, like three to four minutes,
00:50:49
Speaker
We tried to always stop it at 10 minutes because I really don't want people to worry that they're going to be stuck in a long conversation and it really doesn't have to be long to change the culture.
00:50:59
Speaker
And ultimately what, you know, I can tell you about some of the outcomes we found, but ultimately I think that 10 minute debriefing really changed the way people talk to each other the other 23 hours and 50 minutes of the day.
00:51:13
Speaker
So the steps for the debriefing was really a greeting and introductions.
00:51:18
Speaker
an invitation to speak up, and really just a sort of a quick, you know, phrase like reactions to today or any ideas about how it could be 1% better.
00:51:33
Speaker
And in the circle up paper, we listed some other steps that might be listing, you know, successes of the day, any ideas or action items for the future.
00:51:44
Speaker
expressing gratitude.
00:51:45
Speaker
So I usually would close with some gratitude or appreciation for the team's work.
00:51:50
Speaker
And it was pretty loose, conversational, and very sort of team-centered, to borrow a term from, you know, educational circles.
00:52:01
Speaker
Could you share with us, Laura, a little bit of the results of the study and what you found at the impact of implementing Circle Up in your team's
00:52:12
Speaker
Sure, so I'm actually in the process of analyzing the data from our study from last year.
00:52:18
Speaker
So I don't have much of the quantitative data yet, but I think that there were probably three important areas where we've seen an impact.
00:52:30
Speaker
And first of all, I should say, so we took note in a study we did last year, we took notes every day of everything that they said in the debriefings.
00:52:38
Speaker
And then we also interviewed participants and had them fill out a survey.
00:52:42
Speaker
The notes are showing that more than 50% of the time people actually use the debriefing to give each other praise and just appreciation for one another, which I think, you know, had a really incredible impact on the atmosphere of the team.
00:53:00
Speaker
And so what we found is in these three, I think these three main areas is that one,
00:53:09
Speaker
these 10 minute debriefings changed relationships and the kinds of quotes that people offered in the surveys and in the interviews were, I didn't know it would make people feel better just to speak issues on their mind.
00:53:23
Speaker
I thought I was the only one who cared about certain things.
00:53:25
Speaker
I didn't realize other people care the same as, you know, as much as I do.
00:53:31
Speaker
It was a morale booster more than I actually understood.
00:53:33
Speaker
People were looking forward to it throughout the day.
00:53:37
Speaker
It changed the,
00:53:38
Speaker
hierarchy so people said you know i felt much more comfortable talking to people i wouldn't normally approach and um some of them sort of um remarked that the four o'clock debriefings became it sort of became a punitive joke like if they went over to someone and said i need to talk to you about something and then say then they'd say or i could just debrief you about it at four and so um it you know it's just kind of um
00:54:06
Speaker
People would say the debriefings made them realize that everyone's perspective really mattered and they were able to get a much better sense of the goals of other professions and the roles of other professions because they didn't necessarily realize what people were doing as much as they did once they started talking about it.
00:54:28
Speaker
The second area was about process improvement.
00:54:31
Speaker
Some things might seem small, but they had a huge impact on people's day.
00:54:35
Speaker
So for example, the NPs in the unit were never able to tell the entire team, we need our change of shift sign-out to be a protected time.
00:54:46
Speaker
And so the nurses and the NPs, they were able to communicate to the secretaries and the doctors that they really couldn't be interrupted for a half an hour around change of shift because it
00:54:57
Speaker
They weren't leaving on time and they felt like it wasn't an efficient and clear process of communication because they kept getting interrupted either by family or phone calls or someone else on the team.
00:55:07
Speaker
So it sounds like a small thing, but it really changed their experience at work.
00:55:12
Speaker
And then finally, even in a six week intervention, which is like nothing in a clinical intervention, we actually
00:55:22
Speaker
had some significant clinical changes.
00:55:25
Speaker
The most dramatic being that we created a brain box, kind of like an airway box, because this was a neuro ICU.
00:55:32
Speaker
So we were able to get the medications that they need for an acute elevation of intracranial pressure in the unit so that these drugs, which normally were taking 25 minutes to be delivered to a patient because they'd have to put in an order and get it checked by pharmacy and get it up to the unit,
00:55:51
Speaker
were actually able to deliver these drugs within a minute or two um and actually just physically see the you know the um pupils the dilated pupil change or stabilize the you know bradycardia um and then get the patient to the or where they could be decompressed so um they were just amazed that the things that they were saying that they were complaining about um were
00:56:17
Speaker
were actually causing changes in their workplace, and it made them feel a tremendous sense of agency and empowerment.
00:56:24
Speaker
So they just felt more engaged in the debriefing process, but also more engaged and connected in their work.
00:56:32
Speaker
And I sense that the benefits of Circle Up are kind of like a dose responsive.
00:56:39
Speaker
which means that don't let perfection be the enemy of good.
00:56:42
Speaker
And when you start, it won't be perfect, but as you keep doing it and get better at it and do more of it, you probably keep reaping the benefits at a greater and greater rate, but that there's tremendous good that comes just from initiating this, even if your circle up process is not a perfect one at that point.
00:57:00
Speaker
Oh, absolutely.
00:57:01
Speaker
I think that, you know, I think that starting any intervention can feel very awkward and daunting and, um,
00:57:09
Speaker
that it does really help to start with low expectations, start with something small.
00:57:16
Speaker
If I could offer a few tips to make it, I think, to try some kind of intervention and make it successful, I would say, first of all, make sure you have a buddy in the group who knows what you're doing and actually having some
00:57:30
Speaker
kind of promotional messaging before you start can really help so people know what to expect and encourage, and if you have a buddy who's gonna encourage participation and enthusiasm, especially among the different professions, so like one of the unit coordinators, one of the nurses, one of the docs, respiratory therapists, you can start really small, like just make sure you know the name of every person in your unit.
00:57:54
Speaker
I mean, it just feels so much better if you're walking into the unit and you know the name of the medical assistant who has been
00:58:01
Speaker
know maybe not talking to you but who's been helping your nurses for months or years um again as i said earlier i think modeling vulnerability like saying this feels awkward i haven't done this before but i'm willing to try it with you know with your support um one thing we kind of learned through the process was about the physical setting um for people so initially
00:58:24
Speaker
we would come together in the middle of the unit and we found that all the docs and some of the MPs were standing and all the nurses were sitting.
00:58:33
Speaker
And I think it was partly a gender thing because the nurses were women and the docs in that particular unit happened to all be men.
00:58:40
Speaker
And so they were being, I think, sort of like back in the 1950s chivalrous.
00:58:48
Speaker
but it was also because we didn't have enough chairs for everybody.
00:58:51
Speaker
So once we noticed that and we would pull all the chairs out of the break room, everybody sat.
00:58:57
Speaker
Like once they actually had chairs, they all sat.
00:58:59
Speaker
And it really made a difference to have everyone at the same eye level and not sort of towering over people or just like fidgeting because they're standing, even though it's a short conversation.
00:59:12
Speaker
And I think it's important to ask all the participants, you know, what do you think about the timing of this?
00:59:17
Speaker
Of course, they're all going to say, well, it takes time out of our busy work day.
00:59:22
Speaker
But then they'll say, but I can't think of a better time to do it.
00:59:24
Speaker
So we chose our time at 4 o'clock because the attending shift changed at 5 and the nursing shift changed at 7.
00:59:33
Speaker
So in order to avoid interfering with the last minute work of the attending, we chose that time.
00:59:39
Speaker
And it worked.
00:59:41
Speaker
People said, well, yeah, of course, sometimes I'm pulled away from something I'm doing, but I can't think of a better time.
00:59:47
Speaker
And then I would say, don't assume you know what people think about it.
00:59:51
Speaker
You know, you might think people don't like it.
00:59:54
Speaker
I interviewed one neuro intensivist who didn't say a single word in the first two weeks of debriefings.
00:59:58
Speaker
And I thought he seemed reluctant and I couldn't believe his overwhelming positive reaction.
01:00:04
Speaker
Like he just was blown away by how he, and he said, I never want to talk to anybody about anything.
01:00:09
Speaker
I'm like this total introvert, but I couldn't believe how much
01:00:13
Speaker
it changed the feeling of the unit and it made it so much easier for me to approach the nurses.
01:00:18
Speaker
And I think it made it easier for them to approach me.
01:00:20
Speaker
So I would say, don't think you know that people do or don't like it without actually trying to talk to them about it.
01:00:28
Speaker
Could you comment, Laura, as a tip on leveraging existing processes such as a nurse morning huddle?
01:00:36
Speaker
Yeah.
01:00:37
Speaker
I mean, you'll have a lot more success if you leverage a meeting that's already happening.
01:00:42
Speaker
So, for example, if you're already doing a morning huddle discussing the patients, you know, quickly reviewing the patients for the day, you can just add in introductions and make sure that people can hear each other and see each other as opposed to everyone sort of being at their own computer and mumbling.
01:01:02
Speaker
So you can tweak meetings that are already happening to make them more about team connection instead of adding a whole separate thing.
01:01:14
Speaker
Are there any other tips that you would give our listeners if they wanted to start this process in their ICUs?
01:01:21
Speaker
I would say keep it short.
01:01:23
Speaker
I think if you allow a conversation to get to drag on, it won't be embraced and people will feel like they don't want to go because they think they're going to get sucked into a really long thing.
01:01:38
Speaker
One thing that blew me away in our pilot was
01:01:44
Speaker
we never saw phones out or people on computers.
01:01:48
Speaker
And we did not ask people to put away their electronics.
01:01:51
Speaker
That was not at all part of the promotional messaging or in the introduction.
01:01:56
Speaker
We never mentioned that.
01:01:58
Speaker
And in six weeks of this pilot, we only saw two people attending take out their phone for just a few seconds to respond to a text.
01:02:07
Speaker
And other than that, I didn't even see a phone out.
01:02:09
Speaker
And so to me,
01:02:11
Speaker
You know, that's an amazing statement about, you know, their level of engagement in the process.
01:02:18
Speaker
And I think that that happened partly because they were short.
01:02:24
Speaker
So, you know, people are, I think, willing to put away their phone and not be working on other work when they know the meeting's going to be short.
01:02:33
Speaker
But also, you know, I can sort of cynically add that, you know, in listening circles, people say that no one's ever really listening to you
01:02:42
Speaker
as intently as they do when you're talking about them.
01:02:46
Speaker
So this is a conversation about them, and I think they cared about it because it's rare to ask a team, tell me about your day.
01:02:56
Speaker
Were there opportunities to communicate better?
01:02:59
Speaker
Was there missed information?
01:03:01
Speaker
Tell me about your successes.
01:03:03
Speaker
So I think that the audience is very captive because they care about
01:03:10
Speaker
that connection and they care about feeling more empowered and that we were really interested in their ideas.
01:03:19
Speaker
We could talk for hours.
01:03:20
Speaker
I really find this a very, very fascinating topic, but I also want to be respectful for your time.
01:03:25
Speaker
But I do think that it's worth, before we go to the closing questions, to just remind our listeners that innovation is not about technology.
01:03:35
Speaker
It's about finding new ways to do something better
01:03:39
Speaker
and adapting and adopting that in your practice.
01:03:42
Speaker
I think innovation has a big component of it is the adoption, which in your pilot and in your unit, obviously with the Circle Up has been very successful.
01:03:51
Speaker
And I think that what this speaks to is the power that a five minute briefing, several check-ins during the day and a five to 10 minute debriefing with the team and focused on them
01:04:06
Speaker
can have a tremendous impact not only on the well-being of everybody working in that ICU, but ultimately what we really care about is on the safety and outcomes of our patients.
01:04:16
Speaker
Absolutely.
Recommended Readings on Patient Care and Empathy
01:04:19
Speaker
We usually close the podcast, Laura, with some questions that are unrelated to the topic.
01:04:25
Speaker
So if that would be okay, we can go there.
01:04:29
Speaker
Sure.
01:04:30
Speaker
The first question relates to books.
01:04:32
Speaker
Is there a book or books that have influenced you the most or that you have gifted most often to others?
01:04:39
Speaker
Yes.
01:04:40
Speaker
I have to say I'm obsessed with this topic, so my books are not actually totally unrelated to this.
01:04:47
Speaker
I read a lot of novels, which I'm not going to share with you, but I'm going to share with you some of my favorite books that I do gift and talk about a lot.
01:04:57
Speaker
The first is In Shock by Rana Adesh.
01:05:01
Speaker
She's a pulmonary critical care doctor in Michigan, and she's an incredible storyteller, and she became ill, critically ill, and she tells her own story.
01:05:11
Speaker
And it's a pretty shocking description of flaws in our system and in individuals, but she speaks with such humility because she recognizes that until she became a patient, she behaved in much the same way.
01:05:25
Speaker
and her story is riveting and I think especially for critical care physicians it's really eye-opening.
01:05:31
Speaker
Another book that's sort of somewhat along those lines is by Danielle Ofri.
01:05:38
Speaker
She has a book called What Doctors Feel and she's also an incredible storyteller and she, what I, you know, the main thing I took from that book is that emotions are always influencing our care of patients and the empathy that we feel for them and if we don't recognize
01:05:54
Speaker
that we have emotions and that they influence every interaction that we have, we won't feel really whole enough to offer our patients what they deserve.
01:06:02
Speaker
So I think that those two books should be required reading by every critical care doctor or every doctor.
01:06:10
Speaker
Absolutely.
01:06:13
Speaker
I'm embarrassed to say I hadn't read this before, but I just finished the book Being Immortal by Ashul Gawande.
01:06:18
Speaker
Have you read that book?
01:06:19
Speaker
I have.
01:06:20
Speaker
So I think every human should read this book, but especially every doctor.
01:06:24
Speaker
I'm just like, I mean, I wish I had written it.
01:06:30
Speaker
It's like so beautifully written and it captures so much of what's wrong with our society.
01:06:36
Speaker
So he, the first half of the book is about aging and our society treatment of the elderly.
01:06:41
Speaker
And the second half of the book is about dying and what it means to die well or really live well until you die.
01:06:49
Speaker
And so he,
01:06:50
Speaker
discusses the most important questions that we should be asking, you know, all of us.
01:06:55
Speaker
What's your sense of things?
01:06:56
Speaker
What do you fear?
01:06:58
Speaker
What are you willing to trade off to achieve your goals?
01:07:01
Speaker
What matters most?
01:07:02
Speaker
And, you know, he, it's just, it's just incredible.
01:07:06
Speaker
And then the last one, sorry?
01:07:08
Speaker
No, I was going to say that at the Being Mortal, what I found when I read it, very, very transformative was the understanding the tension between
01:07:19
Speaker
providing safety to our loved ones as they age and what they really value, which is independence.
01:07:25
Speaker
Absolutely.
01:07:27
Speaker
Recognizing that has helped me a lot with family members.
01:07:32
Speaker
Yeah, that's a really, that's a really, that was a really poignant part of the book because, you know, what we think people, right, like what we think people value is safety, but it's really kind of paternalistic to assume that that
01:07:49
Speaker
you know, that that's more important.
01:07:52
Speaker
And then the last one I would really recommend if, you know, people are really interested in changing the way they communicate is Humble Inquiry by Edgar Schein.
01:08:01
Speaker
And it's a really short book.
01:08:04
Speaker
It's not medical.
01:08:05
Speaker
It's, he's a, I think he was a, he was a business professor, like, he was a behavioral psychology professor.
01:08:16
Speaker
And he says,
01:08:18
Speaker
Humble inquiry is the art of drawing someone out, of asking questions to which you do not already know the answer, of building a relationship based on curiosity and interest in the other person.
01:08:28
Speaker
And so, you know, if you want to apply these concepts like in Circle Up and actually be curious about and learn about the people working for you and with you, this book about sort of how to bring more humility into how you communicate is really interesting.
01:08:47
Speaker
So we will link these books in the show notes.
01:08:50
Speaker
And I have read some of these, but definitely have not heard of Humble Inquiry.
01:08:55
Speaker
That sounds like an interesting read.
01:08:57
Speaker
So definitely we'll pick it up and let you know.
01:09:01
Speaker
The second question relates to something that you believe to be true in medicine or in life that most other people don't believe to be true or at least don't act like they believe it's true.
01:09:14
Speaker
Oh, yeah.
01:09:14
Speaker
So.
01:09:16
Speaker
I think that one lesson that I learned in life is you should do what you love.
01:09:24
Speaker
And that sounds very cliche, but I spent some time doing something I didn't love, which was working in a basic science lab for almost three years, which was just a disaster.
01:09:35
Speaker
And I learned that you should not persist in doing something that isn't bringing you joy just because you fear disappointing people you respect.
01:09:43
Speaker
because I really respected my boss and I wanted to make it work.
01:09:47
Speaker
And I think a lot of us do that.
01:09:50
Speaker
And instead of really having the imagination or the courage to then shift and say, you know what, this isn't working for me and do something else.
01:10:02
Speaker
And I guess along those lines, my other lesson for life and for work is that there really is no one best way to work.
01:10:12
Speaker
People need all kinds of doctors.
01:10:14
Speaker
Students need all kinds of teachers.
01:10:17
Speaker
And I used to kind of feed my imposter syndrome because I was never one of those doctors who could quote all the current literature and felt like my topic wasn't sexy enough.
01:10:27
Speaker
And I now realize that I have important strengths as a teacher and as a clinician that complement the work of others.
01:10:34
Speaker
So I think that it took me a long time.
01:10:39
Speaker
Maybe it took aging to
01:10:41
Speaker
have the maturity to realize like, it's okay if I don't have some of those strengths, I have other strengths.
01:10:46
Speaker
And so I think, you know, we, we often, you know, feel insecure or as you know, we all know about imposter syndrome because we don't kind of compare well to a certain standard that we think is like the best type of doctor or teacher, but we don't need to, we don't need to be that.
01:11:03
Speaker
We can be our own best.
01:11:06
Speaker
And to that point, I often tell people and think about it myself,
01:11:12
Speaker
that you should always play to your strengths, but I define my strengths naturally as things I do very well, those are abilities, but as things that give me joy and make me feel good about myself and my role in the world.
01:11:24
Speaker
So I find that that's the area where not only you find the greatest joy, but you also have the greatest impact.
01:11:30
Speaker
And I think it speaks directly to what you're talking about.
01:11:33
Speaker
Your strength is talking about communication, talking about debriefing, exploring team dynamics, and not necessarily working
01:11:40
Speaker
with petri dishes and micro essays.
01:11:44
Speaker
Right.
01:11:45
Speaker
Definitely not my strength.
01:11:48
Speaker
The last question, Laura, is what would you want every intensivist that isn't to us today to know?
01:11:55
Speaker
Well, you just made this comment that I think I really agree with, which is that effective critical care is much more about relationships than about technology and interventions.
01:12:07
Speaker
You know, I think that goes for relationships with patients and family and relationships with everyone on the team.
01:12:13
Speaker
So I would say I want every intensives to know that conflict is literally toxic and connection matters much more than you may realize.
01:12:22
Speaker
So recognizing the individual means everything to that person and their family.
01:12:27
Speaker
And it also means, you know, it means a lot to the people working with you and for you.
01:12:35
Speaker
And I think that's a perfect place to stop.
01:12:37
Speaker
I want to thank you first for putting out such amazing work out to the critical care world.
01:12:44
Speaker
I hope that many of our listeners explore your article and try circle up at that ICUs.
01:12:53
Speaker
I definitely will be pushing it along our programs.
01:12:56
Speaker
And I also want to thank you for your time and hope to have you back on the podcast soon.
01:13:01
Speaker
Well, thank you.
01:13:02
Speaker
I really enjoyed our conversation.
01:13:06
Speaker
Thank you for listening to Critical Matters, a Sound Critical Care podcast.
01:13:10
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
01:13:16
Speaker
Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
01:13:21
Speaker
To learn more, visit www.soundphysicians.com.