Good morning. Thank you for joining us for this hour together. So the title of the instructional course is Advancing Equity and Inclusion for Women and my name is Christine Novak. This is Dr. Megan Patterson, Dr. Erica Taylor, and Dr. Susan McKinnon. And so I'm going to give a few introductory comments and then each of these doctors has comments to make. We don't plan that we're going to solve any problems. We're hoping to start a conversation and begin the discussion so that we can sort of more openly look at this complex problem. So you're all familiar with the terms diversity and equity, recognizing differences of individuals in different people, but what the intersectionality is sort of a term that many people aren't really familiar with. And it's really looking at how these social variables interconnect and how they overlap and really add an additive factor to the disadvantaged. Two studies that were done to look at the leadership positions and gender diversity within hand surgery societies and both studies came up with the with the conclusions that these disparities do exist and they're really accentuated at the leadership level. We recently did a study looking at the invited and peer-reviewed presentations at the hand surgery meetings at the Hand Association and the Hand Society in 2010 and 2020. And what we found is there was an increase in female invited speakers and but there is still a significant improvement in gender diversity. And just looking at the graph there, the blue is males and the black is females and so that color difference in what you can see in the amount of blue shows the amount of variability and the lack of female representation. So the talks today, Megan's going to present on barriers and balances, Erica's going to look at the academics, and then Susan's going to look at effective coaching and mentorship. And we're probably going to keep the talks short in order to have time for discussion. We only have an hour and so we want to encourage that. I don't have access to the app to the Q&A but the group is small and I think that a discussion amongst would probably be best. Yeah, you've got to come sit in the front row. They're the most comfortable. Should I get the guy? I mean, no. There you go. Just be patient. Everybody just be patient. OK. So thanks, everybody, for coming. Again, I'm going to be talking about barriers and imbalances in surgical practice. And as I was getting ready for this talk, it's a broad topic, and I tried to organize it into clinical challenges, interpersonal challenges, and then personal challenges. And then before I get started, a lot of the literature I'm going to talk about comes from orthopedics. I'm an orthopedic hand surgeon. I know there's lots of plastic surgeons here with us today, and plastic surgery does a better job than orthopedics in terms of gender diversity. But these issues are really universal to hand surgeons, whether you're a plastics trained or ortho trained. So starting with where do we work and what do we do? So we know that 50% of medical students right now are female. That drops to about 13% of orthopedic residents and then drops further to about 6.5% of orthopedic faculty. Most women work in either academic or hospital-employed settings, more common in hand general orthopedics as well as pediatrics. How are we paid? In the private sector, there's lots of information out there about the wage gap that exists. Unfortunately, that exists also within medicine and certainly within orthopedics. This is a study from 2019 looking at data from the AOS Census from 2008 and 2014, and there is a persistent, actually increasing, income gap between males and females, even after they controlled for all the things that we know affect income. Specialty, subspecialty, case volume, hours worked, years in practice, work status, practice setting. Despite controlling for these variables, there remained an 8% sort of unexplained gender gap in terms of income, and that gender gap exists across medicine, subspecialties, surgical subspecialties. It's been looked at extensively. And no one really knows why it is. You know, there's probably a lot of things that come into play, but disparities in leadership play a role in that. As you start in the medical school years, again, 50% of students are female. That drops fairly precipitously for women over the course of their medical career, while it increases for men as they advance through academic and faculty positions and then finally to the leadership level. Referral patterns also play a role. This is a nice study out of Canada from earlier this year looking at referral patterns to male and female surgeons. And so on these two graphs, the dashed line represents the percentage of the male and female surgeons in the population with male surgeons on the left side and then female surgeons on the right. So anything above the dashed line represents over-referral. Anything below the dashed line is an under-referral. So on the left side, those are referrals to male surgeons, and you can see on almost every instance, with specialty or the referring physician, on almost every instance men are getting over-referred to as opposed to on the bar on the right side where in almost every instance females are getting under-referred to. The exception to that is that female surgeons tend to refer to female surgeons. Referral patterns has also been looked at in terms of new case volumes. So female surgeons controlled for training and seniority see fewer new patient referrals per month. Female surgeons tend to receive more non-procedural referrals, which we know is those procedural referrals that really drive our surgical volume. When patients of female surgeons have a poor outcome, it's been shown that referrals to all female surgeons decline. And the same is not true for men. So if I do have a poor outcome, referrals to all female surgeons from that referring provider will go down, whereas if my male partner has a poor outcome, they just keep chugging away. And that's been shown in a study of Medicare referrals. So what can we do about this? Talk to your practice, talk to your department, your division, about a single-entry pooled referral model where all the referrals come in and then they get sent out to the first available appropriate surgeon to try and balance some of that bias in referral patterns. Moving on to interpersonal challenges. So managing expectations and navigating staff relations, I would imagine, is something that we've all had to deal with. As women, we are expected to conform to certain gender roles, and socialization is seen as a matter of survival and success. And this includes the chit-chat, sharing photos, participating in potlucks. And while these things can absolutely be lovely and build a sense of community in the workplace, they impact our efficiency, they increase our work hours because we can't be doing our work if we're chit-chatting, and they can decrease satisfaction, all of which can increase emotional exhaustion and burnout. And these interactions often will change as we advance in our career. In the early years, there's some bullying and discrimination as we're trying to find our place and kind of receiving some pushback from staff members. As we enter our mid-career years, often everything's more comfortable, like we're accepted and it's okay. And then as we move into late careers and perhaps assume more leadership roles, these relationships often become strained again as there's a sort of feeling of being threatened, especially from staff members. Harassment, discrimination, and bullying is prevalent within medicine, certainly within orthopedics. And this was looked at in a study a couple years ago by Samora et al. They looked at a survey of women and underrepresented minority AOS members, and they were matched with non-URM men to assess the climate of workplace safety and culture. And of those studies, 66 responded that they experienced discrimination, bullying, sexual harassment, as well as harassment, with women being more likely to experience these behaviors than men and women being more likely to experience sexual harassment. Another study looking specifically at sexual harassment of residence fellows and faculty was sent to the members of the Ruth Jackson Society, and they found that 68% experienced sexual harassment. Only 15% reported that harassment and that there was unfortunately no difference between current trainees and faculty surgeons, suggesting that perhaps we're not seeing a significant improvement. The types of harassment that these women reported ranged from verbal remarks up to sexual coercion, stalking, assault. The perpetrators of the harassment were predominantly, far and away, male attendings and male co-residents. Patients did play a pretty strong role, again, behind their colleagues, behind their attendings, their partners, and their co-residents. Harassment, discrimination, and bullying is associated with poor mental health, low self-esteem, productivity, high levels of absenteeism. So obviously changes are needed, and what are those changes? Every hospital, every division, every department needs to have a clear and easy process to report these behaviors. There needs to be a transparent policy for accountability with strong leadership from senior members of the group. And I would encourage everyone in this room to find your allies, no matter what level of training you are, and at every opportunity, be an ally for those people who are lower than you on that medical totem pole. There's such a hierarchy in medicine that, you know, the people at the very bottom feel as if they have no power, but a PGY-2 has more power than a 1, and so be an ally to those people that are below you because a little bit of support in this arena goes a long way. Last thing I'm going to talk about are personal challenges, and I want to talk a little bit about confidence. So this has been looked at, again, in the private sector extensively, and in general, compared to men, women don't consider themselves ready for promotion. They predict they're going to do worse on tests. They generally underestimate their abilities and performance. They're four times less likely to initiate salary negotiations, and when they do initiate negotiations, they ask for less money. Women tend to apply for jobs in promotion when we meet 100% of the qualifications, whereas men will go up for that job when they meet 60% of the qualifications. So I don't know, guys. Keep that in mind when you're applying for jobs. You know, women in general, we feel confident when we're perfect. We don't answer questions, especially in a public setting, until we are 100% confident of the answer. This lack of confidence causes us to assume blame when things go wrong. We credit circumstances or other people for our successes. It can lead to inaction, and it can cause imposter syndrome. Especially in surgical training, it's important to remember that confidence does not equal competence. Confidence in surgical training has also been looked at, and in general, female residents underestimate themselves compared to their male colleagues. They have lower operative confidence at the end of residency than their male residents, and so these attitudes will then cause them to appear less competent to their faculty. They are then given less autonomy, operative exposure, and practice, and then this cycle of decreased confidence persists. So, you know, women tend to be in this sort of catch-22 position because it's been shown that if we show assertive and confident behavior, we are going against traditional gender norms, which makes people uncomfortable, and it decreases our likability in constrained relationships. So women often tend to suppress their leadership qualities to avoid backlash and allow them to fit into these more traditional gender roles. The last thing I'm going to talk about is work-family integration. This perceived inability to achieve a work-family balance is the most common reason cited for why women choose not to specialize in orthopedic surgery, and this has been studied extensively. It's actually like, you know, if you look at these references at the bottom, they're recent. You know, there's a lot of literature coming out looking at this, which is encouraging, and females are more impacted by work-family conflict. We tend to get married later and delay starting our families, so this study showed that two-thirds of male surgeons had children during residency, and two-thirds of females had waited and delayed their family until after their training. Women more often in orthopedic surgery more often require fertility treatments. This was a study by Poon in 2021 that showed the age of first conception, infertility rate, miscarriage rate, pregnancy complications were higher in female orthopedic surgeons than in the general population. We carry more responsibility at home. Male surgeons reported spending greater than 12 hours a week caring for family, while male surgeons reported spending less than 3 hours a week in those same roles, and we tend to have fewer academic and leadership roles. These conflicts and this work-family integration sort of disconnect can cause burnout or contribute to burnout, which is present in about 70% of surgical trainees, 40% of practicing surgeons, and it can be up to 60% higher in female physicians than in male physicians. So what do we do? How do we ensure the success of women? Increase mentorship and sponsorship, and Dr. McKinnon is going to talk about this in a little bit. Try and address these unequal standards that exist for women, these sort of need to conform to traditional gender roles. Reduce women's professional and social isolation. So this sort of talks to this feeling of the old boys club, and sometimes it's hard to break in. That old boys club is where relationships and mentorships are fostered, and if we don't have access to that club, it's hard to build those relationships. Increase attention to promotion and salary equity. Improve work-life integration. Address harassment and bullying, and expand recruitment efforts, especially in the early years of medical school. The last things that I would put on there is believe in yourself and know that you belong and you deserve your success, and I think especially in your early years of training, you just say that to yourself over and over and over again. Know that your experiences are valid. There is data to support all of this. So these things that you might be experiencing in your workplace or your training, they're valid. They're probably real. It's probably not in your head. And then the last thing I would say is build your tribe and protect your peace. Find what you love, do what you love, and put yourself on your island of excellence if you need to if things are feeling a little overwhelming. With that, I will pass it off to Erica. Thank you. So, I'm a hand surgeon, I'm sorry, that was a bad introduction, I am a hand surgeon, I'm 13 years in practice at University of North Carolina in Chapel Hill, yes, I'm vice chair of diversity, division chief of hand surgery in my department. And Megan, clearly I don't have enough patience, like just relax, you just need to relax, but good afternoon or good morning everyone, I'm Erica Taylor, I'm in my 10th year of practice at Duke, I, there we go, am so excited, I am working very hard to rein in my energy, if you know me, that's sometimes difficult for me to do, so we'll go ahead and get started, but Dr. McKinnon, list is here, this list is semi-relevant, usually when we do these talks it's not, but today my job is to talk about the academic promotion and leadership navigation journey, specifically for women, one thing you could do is rename this, why is it so hard to be valued and have opportunity, because that's really what the question is, and I know we started by saying we only have an hour, we're not going to solve everything, and sometimes when I give these talks, people say at the end, the right people weren't here, what do we do about the people who need to be here, I will offer an alternative perspective, you are the right people who need to be here, and so what I invite you to do as I go through these slides, as Dr. McKinnon continues to speak, is to take out your phones, take pictures of these papers, because when you go back to your institution and environment, more likely than not you're going to be asked what are we supposed to do about it, and I hope you will have gleaned some different ways of describing these issues, and importantly the solution, so the framework I like to use is self system and strategy, so we're going to go through it in that order, self, how identity, the humanistic aspect plays a role in what we're talking about today, system, how our environment matters, and then lastly strategy, so over the last few decades we've heard our chairs, division chiefs, each other promise for change, but how do we really execute on those commitments, and so I often get the question, Erica, look at your titles, I don't see color, your identity doesn't matter, everything is equal, shout out to my new friend in the back who heard this last night when we were at a dinner, there's no need for diversity committees or work anymore, why do I think identity still matters, talks like this are still important because of a picture like this, so I'll be honest, I've not ever heard a trailer watch this particular character speak, however the image of her has stirred up so many sentiments just by a visual, and the spectrum is wide, I'm so proud, this is going to be great, my daughter sees herself in this mermaid, to my childhood is ruined, this is blasphemous, why can't they just make a whole new story, why are they ruining a story, just from a picture, so I invite you all to consider that perhaps our identities still do matter today, and I appreciate Dr. Novak bringing up the intersectionality, that's a real thing, and so let me give another image, I am aware of my process of chronological increase, so this is what I'm referring to, it's a TV show called Quantum Leap for those who don't know what I'm talking about, but this is a new reboot of it, and so when we talk about identity representation, why it matters, why seeing yourself in public circles that are championed makes a difference, those are the two images I'll share with you for that, now I'm not going to spend too much time on the data, Dr. Patterson did a wonderful job, I hope you took some screenshots of that, or I hope you're familiar with these landmark articles, the results should not be surprising, in this particular study they aggregated 35 years of data of what is the days to promotion from assistant to associate, associate to professor, comparing men to women, this is a Kaplan-Meier curve, usually we look at it in terms of time accumulation of risk for survival of certain diseases, the take-home point is at no point between the male curve and the women curve do they ever cross, so despite decades, whether it's the Hand Society, the Plastic Surgery Society, AOS, of all of these talks, for some reason women advance at a rate that is slower than men, now it's multifactorial, so we'll get into that in a second, this is another story because we're talking about leadership that was recently published, I did a commentary in Ortho Today recently that showed, well as you would expect compared to other specialties when you compare 2007 to 12 years later, the number of women as well as different race and ethnicities has really lagged behind in terms of chairmanship and chairwomanship, division, department leadership, program director leadership compared to men, even though we have asterisk because it's significant, we went from zero to five, right, in 12 years, that's great, look at the other specialties, what's happening, why is it so hard to do this, those are common themes you'll hear about, Dr. Patterson alluded to these, antiquated promotion process and an adequate pipeline, I often will state we think of pipeline as high school, maybe even elementary school to college, to medical school, once you match, the ball's in your court, we're done, the pipeline for post-match residents to fellows to peers is very, very shaky, we'll talk about that in a second, representation, so we've done maybe a fairly good job with the D, representation, but when we talk about choice, authority, opportunity, the equity, inclusion, belonging, the E, I, and B that comes with the D, we're not really focusing on that as much as the D, maybe the D is easier to measure, maybe it makes us feel good, but then why is turnover so high, why are these curves still not crossing, it's the E, I, and the B, and then Dr. McKinnon's going to talk about mentorship shortcomings, but I did want to spend just a few minutes on this, because while we're familiar with these definitions of mentorship, the personal connection relies on great communication, the sponsorship, the advocacy, putting each other in the room, and we can't be in said rooms when decisions are being made, and these leadership appointments are being discussed, there is something called inclusive mentoring, because as we talk about intersectionality, matching someone's identical background, identity, experiences, it's going to be very difficult, so in the short term, how do we mentor across differences, well, you know, Dr. Taylor, I do that all the time, I have mentees who don't look like me, I'm a champion, I would actually recommend that we consider that perhaps there are some barriers that are keeping us from doing this correctly, I'll just touch on three, the first is a traditional view of success, we rarely ask junior mentees or our peers to define what success means to them, we often emphasize you should really publish, you should really be in the society committee, because then one day you can lead the society, you should get this award, I'm going to put you up for this award, you should do this presentation, these are not the only metrics that matter, we can't all be the AOS president, we don't all want to be AOS president, so we need to back up a little bit and understand what is another person's view of success, is it entrepreneurship, is it investment, maybe you want to go into venture capitalism, is it investing in their family, personal achievement goals, another obstacle is this diminished value of achievements, if you know me personally, you hear me lament about this quite a bit, when I was applying to medical school, someone said in a letter, she is a rising star, to this day, if there's an email introduction, someone say, I want you to meet Dr. Erica Taylor, she's a rising star, I am 41 years old, at what point, what do I have to do to no longer be rising, because what the message is to me is that, oh, your work's not done, you've not done enough, you are not a star, so someone's going to have to keep lifting you up, because you are not complete, so what is that based on, is it my appointment level, quite frankly, I don't really care too much about that, is it the circles I'm in, they're not perceived as valuable or important enough, etc., so you get the idea, the last thing, Dr. Patterson, you and I are in the same wavelength, she referenced this article about how when we share these truths, someone in our industry forums yesterday called them unspoken truths, the response is, it's not really them, it's you, oh, that's just the way they are, that happens to everyone, perhaps you're just too sensitive, and so the imposter syndrome Dr. Patterson mentioned can be exacerbated when we trust our mentors, and they tell us that what we're saying and experiencing is not really happening, some will refer to that to an extent as gaslighting, so another term we've heard about recently, so this is a qualitative study, I really enjoy this, because even though I did not contribute, the sentiments are as if I contributed to this, and so they asked women surgeons about interprofessional workplace conflict, specifically in the OR, not man to woman, but woman to woman, the interesting thing about this study is that while there were all of these factors at play, and you can read them here, the most important point that I want you to take from this is that the women surgeons did not perceive this to be malicious intent on the part of the perpetrator, but rather a reflection of society and cultural norms, when we do this work, when you go back home, when you talk even later tonight at your society club dinners, remember the aspect of grace that is required to make these conversations productive, so here's some of the sentiments, I see one of my former attendings in the audience, she may attest that in fracture conference, when I saw something that was really wicked, I would sort of do this like church, ugh, you know, terrible femur fracture, looks terrible, so feel free to do that as I read these things to you, so one, guys tend to do a lot of ranting and yelling and throwing things, and it's just like completely ignored, I don't get that, I know some attendings here, they got into a fist fight in the OR, and I don't think anybody gets into a life coach, right, it's just like stunning to me, I think for women, if you get upset or react, you're considered emotional or reactionary, whereas if a man does it, they're being assertive or advocating for their patients, and then I was stunned at the end of the meeting when he told me he understood that, yeah, sometimes men and women who may say the exact same thing in the exact same tone, we may be perceived differently, and I was very happy to hear him acknowledge that, but in the very next breath, he said, maybe you would like to pursue some coaching to help with the way people perceive you, thank you, so self-identity, I mentioned nothing about ability in any of this, this is just what happens by being who you are, it also matters where you are, so we're going to dive into system, I'm going to show an article, but this is a quote from it that really struck me, it says, cultural values are the values of founding leaders, are adopted by subsequent leaders and members of the culture, are kept firmly in place by policies and procedures that were developed and implemented over time, hashtag facts, and so even if we are in that leadership role, what do we do? We try to mimic what that leadership role should look like, be like, we perpetuate the culture, and then simultaneously, in a room we're not in, policies are being made to make sure that said culture is in place, that aerial is never redrawn. This is language I want you to leave with, because if you have the privilege of sitting with hospital administration or revenue drivers or managers, they often will talk about the business case of diversity, so if we're talking about promotion and putting women at the top in the c-suite, often you will hear things like this, and these are from fortune 500 CEOs, the business case has been made to demonstrate the value a diverse board brings to the company and its constituents, the case for establishing a truly diverse workforce at all levels grows more compelling each year, the financial impact makes this a no-brainer, the business case is clear, when women are at the table, the discussion is richer, the decision-making process is better, and the organization is stronger, I mean that's a lot, right, just from us being in the room, they say, these economic benefits, they actually come from a McKinsey study from 2012 that showed that there's these financial gains, and so to be more effective, we need to look and think like their company, based on ortho, that's the hashtag, I look like a surgeon, we need to look like our patients to deliver the best care, the American College of Surgeons lists said benefits in a healthcare frame, why doesn't this work? Well, it can backfire, it can actually be a turn-off for women who are applying to companies where they are seen as, we want you because we want more women, it'll make us better, it assumes that underrepresented candidates offer different skills, perspectives, experiences, working styles, it frames it not as a moral necessity, but as a business asset, it suggests that you can judge a candidate's contribution based on their identity, which leads to stereotypes, depersonalization, and an undermining of a sense of that be belonging, so what does this also manifest as? Well, if you need a woman in the room, usually they don't say one, but they mean one, but then a second one comes, she and I are interchangeable, so do I want to be in a department, do I want to rise up the promotion train, do I want to be on that board when I can easily be exchanged? This is from the Harvard Business Review, you can read this here, but this warns against the add diversity and stir approach, instead it challenges organizational leaders to reshape their power structure, so this is from the British Medical Journal, I shared that quote a few slides ago, and they did a systematic review, they found about 4,000 articles that talked about women leadership academics, they whittled it down to about 40, what they found were two different phases, so when you go back home and you talk about women in leadership, talk about these two phases, one, leadership emergence, how are women leaders identified? Now, it's often conceptualized with the pipeline metaphor, suggests that if you increase the number of women, let's say in hand surgery, it'll lead to an increase in the number of women leaders, now one of the fallacies is that it takes this pipeline, says put a bunch of people in it, and it makes an assumption that there are a bunch of people at the end waiting for them to be role models, mentors, etc, and that's simply not everyone's truth, it misses pertinent organizational nuances, the absence of role models, career influences, and the complexity of healthcare organizations, hindered by requirements, that's distinct from leadership enactment, you have the role, how do you perform and execute in that role? Most of the studies they reviewed were drawn from a backdrop of foundation, a control group of male leaders, that's when you talk about the great man theory, which is leadership is equated with authoritative and assertive qualities, the collaborative theory for women, work together, emphasize social accountability, Dr. Patterson alluded to this, this is often termed the double bind, I had the wonderful pleasure of meeting this author just a week ago, today actually, Dr. Shasha Shilkat, I don't know if any of you are part of her organization Brave Enough, but she's a cardiac anesthesiologist in Nebraska, and has devoted a lot of her time talking about this spectrum between grit and grace, how to be feminine and formidable, I love this tagline, it's okay to be bossy, and so one thing, and Dr. Patterson alluded to this a little bit, that she talks about is this spectrum of leadership backlash versus social backlash for women leaders, particularly women physician leaders, and what it says is, if you are assertive, authoritative, direct, you may be considered a great leader, but nobody wants to have coffee with you, nobody wants to really talk to you, connect to you, that's called leadership backlash, conversely, if you're nurturing, nice, we see this, I saw this as a resident, if you are a team player, that's great, but is she really a leader? The take-home point is, no matter where you are, there's backlash, so just be yourself, and it's not to scare you, it's to let everyone know we are in this together, we feel these things together, you are validated, so last but not least, I will leave you with just a little bit of strategy, first and foremost, please learn about cognitive biases, this is relevant in residency selection, fellowship selection, hiring processes, promotion, and leadership appointments, we know these, we have these, we all do, it's how our brain creates shortcuts to protect ourselves, but anchoring the confirmation bias, this confirmation bias is really what shows up a lot in healthcare, where if someone says, leader X is very assertive, every time she says something, you're like, yes, even if it's contradictory to the facts, framing how we talk about each other, and then representative heuristic, well, we had a woman here before, she was great, so you're going to be great too, or we had a woman here before, she didn't do too well, you might be an academic risk. Practice humility, again, the right people are here today, the people who need to be here are, if we had more chairs, maybe more people would be here, Chris, we talked about this earlier, but we have to understand that our own templates should not serve as the absolute benchmarks for success, we have to actively listen to the people who are trying to be promoted or trying to reach leadership pinnacles, making space, even if that means we need to step back, and then do not be afraid to uplift someone who has a different set of skills or who may be better at something than you. For those who have an ability to socialize the idea of modifying your promotion track, I refer you to Indiana University, Purdue University, who paved the way over a year ago by being the first institution to add a DEI scholarship category to the promotion tenure track. What does that mean? Well, they actually took the existing promotion side and said, if you were a scholar for things that helped marginalized communities or improved equity or belonging, you get credit for that too, not just publications, not just society leadership. I actually was able to take that, I met with one of their deans, she gave me their intel, and then I applied it to my department. So we just finished our first year of academic review, which is a surrogate for the promotion track, and we have now a DEI category. This is small on purpose, but if you take a picture, it'll blow it up on your phone. Feel free to use this, email me, I'm happy to give it to you, but in addition to what society have you led, how many presentations, publications, who have you taught, who have you mentored, have you closed your clinic charts, now our faculty can add scholarship in the three subdomains of DEI, service, discovery, education. And it's not, did you show up at an 8 a.m. talk at the Hand Society? Check. No. Did you show up and give said talk at the Hand Society? Did you create a curriculum? Did you partner with a historically marginalized college or university, otherwise known as HBCUs or MSIs? This was successful, I'm happy to talk about it after this lecture with you more, but this is what we've talked about now, self-system strategy, a different way of looking at how to get us up through that incomplete pipeline so that we are successful as we define it. Here is my value and my opportunities. Thank you. Erica, that was, that was terrific, and I, patience is my strongest value, no it's not. I've learned that, Dr. McKay. You know, I have, I've finished a year and a half of coaching. I, as, as Megan's bringing this up, I was, I got the other coaching, the other coaching, get the coaching or get a new zip code memo. And wow, it was how to deal with this hierarchy and suck it up. And then, which helped me survive. And then I fell into this other coaching, positive energy coaching. And my life has changed and changed. And I have control. And I wanna share that with you. So I was sitting over here thinking, oh, vulnerability shines a light on the way forward, on the path forward. And then I go with your intuition, Susan. I don't know, I'm not that brave. And then I thought, duh. Look, see what comes out of your mouth when you stand up here waiting for your slide. And that's what came out of my mouth. So mentor. Mentoring is a word. We know what it is. A couple of things I could add to it is that it really is advice. You're getting advice that has been there before. And of course, it's dated. But as Megan was saying, there are some things that are still the same and haven't changed. And yeah. But I think importantly, it's based on trust. We do assign mentors at our institution, but you can't really assign mentors. You're assigning career advisor type of thing. One of the things that I know now to be true is that we have our paths. We don't know where they're going. We'll click into a mentor and we'll mentor someone and then boom, they'll go off in a different path because their path is different. So there is almost always a limit to the timing of the mentoring. And when it falls apart, if it's been good, it's been tight. And when it falls apart, it feels sad. And sad. And some, it's just sad. And you need to know that so you don't stay sad. And I'll tell you how not to stay sad. The other, and Erica touched on this, it's very easy for me to mentor a medical student. They know nothing and they're so excited and they have so much energy and they're so happy and they're so easy. Mentoring someone you're equal is a little harder. And mentoring someone who wants to be better than you in what you do, that takes a pause. And a short pause because it is different and it is really mentoring when you can take people then and push them up higher and promote them higher in something actually that's meaningful to you. So be aware of that too. So coaching, it's different. Sponsorship we know is important and I was so on that a few years ago. Megan and Chris and I made a great classification of sponsorship. One, two, three, A's and B's, very surgical. And it was a sponsor and it was an ally and then it was the dis-sponsoring and then active dis-sponsoring. I have been exposed to all of that. I have had lots of active dis-sponsoring. So it felt really good to make this classification. It got published. But coaching is the person that you're talking with is the expert. And Erica, you've said that. We have everything we need right here, right now. We are perfect, amazingly perfect. Imagine if we're not perfect in ourselves and own our beauty, our magnificence, how about all other people that need to be pulled up as Megan and Erica were talking about. So if we're perfect and we know we have all the tools inside of us, well, we don't feel like that often. And so a coach comes in, in this coaching that I've been taught, which aligns your inner purpose and your passion of who you really are with what the goals you are wanting to achieve, which sometimes you don't even know, Michael. Do I wanna be an associate professor? Do I wanna be in academics? Do I wanna go to private? You don't even know. Don't wanna have children? Don't wanna get married? Don't know. But by aligning it with your inner purpose and your passion, that's the ticket. Okay, so surgeons, I have these videos on how to do an operation and it's step by step by step. Have any of you seen my videos? We love them, yes. Yeah, okay, so I like step by step. Tell me what to do and I'll do it. So these are the steps for just being. So if you look here, and this is Bruce Schneider's work. He has a book on energy leadership and I did 500 hours of trying to be better and everyone who knows me has been coached by me and they're both sick and tired of it, but some of them are, so maybe my husband the most. So you start with the lower levels, energy one and two, which are sympathetic. Fight, fight, or freeze. And then you move up to the higher levels of energy where you get to the very top, where you have no ego, where you're just being, and at the high levels, you're connecting, you're inventing, you're creating, you're in the flow. So the sympathetic nervous system is on massive overdrive when you are at a level one victim. I was put by a level two person to a level one in June of 2020 and I stayed there for about a year and a half. It was horrible. I felt miserable. Some, Megan said to me, you've lost your joy. Do you remember you said that? You lost your joy. Whew, and I thought no one knew, but I'd lost my joy. I was like down. The next step, the first one is I lose. That's the victim. All of these levels are driven by a thought, preconditioned, learned it somewhere, that tells you, I'm not good enough, they said I wasn't good enough, therefore I'm not good enough, and then I'll be sad, and I'll be fearful and anxious, and I will withdraw. So a thought drives an emotion, drives an action, and it's predictable. The next level is, I win, you lose. That's a very common mentality in business, and even in academic surgery. I win, Plastics wins, but Ortho loses. Ortho wins, but Plastics loses. I win, you lose. And that is conflict, that's anger, that's entitlement. The third level is, I recognize these emotions are not healthy for me. It is what it is, and I can deal with it. And I can forgive it, because I don't like that. Then the next one is level four. We are all at level four. Level four is healthcare. Level four is you win. You win, I give compassion. Level four is looking after your beautiful family. So we're level four-ing all the time. You're giving your compassion all the time. And you feel good, because you make people, you're fixing things, and people feel so much better. So that's a nicer feeling, right? Ah, but level five, I love level five. I work level four. I love level five. Level five is win-win, not attachment to outcome. We both win. Learning, there's opportunities everywhere. There's no dumb question. I'll learn from whatever. Level six. So at those three levels, those middle levels, we're doing things, we're busy, looking after patients, looking after family. At the low levels, we're just so needy. I want this. I feel badly. All about me. At the level six and seven, that's where we're just being who we are. And it's easy, because we're authentic. We're not covering anything up. We just are who we are. And we're really great when we get there. This is so much fun. I love this. I love being a surgeon. I love nerve surgery. I love my family. This is where we float. This is being in the flow. Those high level seven, we've all been there. That you're doing a case. You put your head down. You lift your head up. Four hours has passed. Where to go? You weren't attached to outcome. You were just being the surgeon that you are, working with the team you're working with. And everything was wonderful. I see people nodding. We know that feeling. And that feeling is high bliss, high passion. So, when you're at those two levels, those low levels, you have high judgment of yourself or others. There's a lot of sympathetic overdrive, stress, fight, fight, freeze, adrenaline, cortisol goes up. It's not healthy for you. And you're very attached to outcome. So along the line of, Erika, what you're talking about, we want high performance. We want people to be, you have to let people be their authentic self. Women in the room, how many of you have packed high heels in a purse and flats when you walk here? Or careful what you're going to wear. See some black in the audience, some dark navy blue. I see an orange. Da-da-da-da, and a pink, da-da-da. But being your authentic self, that's going to take you there. So let me just go through this quick with you. And I love Erika's generosity of the slides. And we'd be happy to figure out a way to click you the slides so that you wouldn't have to take the pictures of them. So level one, just for an example, the thought, the emotion, and the action. I'm a victim. You told me that. Someone level two'd me. I feel fear, anxiety, shame. I'm just going to go high. For a level two, very much judgment. Everything's black and white. My way or the highway. Anger, entitlement, control, blame, aggression. Level three, oh, I can breathe. I recognize those two levels are not sustainable. I want out. I'll cope. I can cope. I'm safe. And then level four. Synergy, working with joy and happiness is six. Joy and happiness. And I know from taking this, where you can do a little energy test, I float around five, six, and seven. That is my natural being. Under stress, I go right down to a level one. I learned that from my mom. She was a fabulous victim. Level seven is no judgment, and this is high, high level of performance. We all have this, right? We have this inner critic. Usually came from parents that wanted us to do well and be safe. Don't cross the road. Don't get back from the edge of the tower. Don't go down that black diamond. Don't, don't, don't. Be afraid, be afraid, but do well in school. I want you to do well in school, and that little gremlin is the little person that tells you you're not good enough, and that really served you well to get where we are here, and it does not serve you now at all. You need a different message, and that little gremlin, in an instant, in a moment, will give you a different message, but it's not going to give you a different message until you have a new thought. It's just going to give you the default junk until you say, as I walk out this room, I am going to give myself a different message. My message is I'm fearless, I'm confident, I'm powerful, I'm authentic. I still was gremlin-ing myself over here when I would even tell you that story. Why am I talking about this? Why is she talking about this? There's a reason, and the reason was I hated level one. It was horrible. I hated it, and I couldn't get out of it, and now that I know the tricks, I want to share the tricks. Okay, so here you go. You just have an old thought that drives an emotion that drives an action that you don't like, and it's not serving you, so you just have a new thought, a new emotion, and a new action. Oh, that's easy. Great. Okay, great. Okay, I see that yellow arrow. Okay, what's in that yellow arrow? I can't get out of the level one. It is June of 2020. Now it's June of 2021. I was a deal in this muck, and I know I'm driving people that love me crazy, so how do I get out of it? So here's how. Let's go back to 1946. Viktor Frankl, just out of the concentration camp, and he has his book published, Man's Search for Meaning. 1946. The answer's been there for a while. Between stimulus and response, there's a space. It's a very short time between a stimulus that will give you that default pre-programmed response, but there's a space. There is a space, and that is the way in. That is the way forward for growth and for freedom. That gives you the power. moment by moment, but know that that stress is going to come, that pow, that level two-ing is going to come constantly. In little bits, like, ugh, or big bits, like, I'm papering you. Go to coaching. And you need to practice. It is a practice. I love the little tiny microaggressions because I feel them. I'm so sensitive to them. And I go, OK. Okay, so how so he tells you there is a space and this is possible in that moment. There's a space and it's a brief moment Okay. So now how do you? Find that space Quick enough not to do your regular response. So I've also studied yoga certified yoga teacher 600 hours meditation red pima shodrom fabulous fabulous Buddhist monk and And the All that meditation stuff is basically around breathing. So you just do a slow breath It's like you say to get take go sit over there and take ten breaths and come back behave yourself So if you're a practitioner you can do this in three breaths You can take yourself as soon as you feel that feeling remember there's thought drives an emotion drives an action You feel a feeling before you even have the emotion and that is coming from a thought a belief that you talked about that creates Then bang comes the feeling oh And then the emotion and then you've lost it and it's a very short Yeah, I have flooded twice in front of my chairman. Yeah, so It with no control over this at all, so there's the stimulus and how do you handle it you go with the feeling and for the Men in the audience, maybe some of you were taught not to feel things Don't cry when this is the deal right women can't do science and guys don't cry So with that feeling that's gonna tip this whole next Movement, you can see it coming in the stimulus you go immediately to the breath just Just take three slow breaths and that breath can expand your space you can feel The breath you can feel the breath you can feel it as you can feel it in your belly You can feel it in your chest. It expands the space and in that space That is where Viktor Frankl says in that space you make a conscious choice and you change the thought Say look you can I am powerful. I am fearless. I am level 5 win-win. What can I see out of this? the last time what I in that June moment when I was level 2 and went down and flooded I offered Could I have coaching? I? Don't know. I never I don't know any more coaching and that that came from Intuitive level 6 is high intuition. It's like me saying well, don't worry about it. It'll comment doesn't matter Trusting your intuition. We think these thoughts are all pre-programmed and maybe they'll help you But maybe they won't and you need to make that choice to know do I really want to be that person? Do I want to be that person that that is? small Do I even want to be things I thought I wanted to be I always thought I wanted to be president of the hand society I I always thought that I thought that's what I should be But I shouldn't I wasn't meant to be and why not? That's a good question later talk. So So here let's try it in action. I've got a minute or half now. So awareness acceptance conscious choice trust Okay, so the when you feel something that your body doesn't like or some eye roll or something Awareness you are aware of that feeling before anything else happens as soon as you feel that Shiver or that that grab at your throat. I'll be aware and start your breathing. Just slow it down Slow it down. Think about it inhale Exhale. Oh, okay. I mean we could try that right now Whoo accept it, you know, that's coming Don't you know it's coming and either you're gonna do the default Nonsense or you're gonna make in that moment in that moment You make need a different thought or different a different emotion a different action So it's always level one you're getting level two when people come at you You're gonna go to level one or you're gonna punch them in the nose either You're gonna withdraw you're gonna punch them in the nose. Neither are very successful So you accept that and you go immediately to level three and you say I can cope with this. I see what's happening Ah, I see what's happening. And then you're you're breathing all the way through this, but you're focusing on the breath You're focusing on space creating some space Pushing the little gremlin aside creating some space make a conscious choice Go to level four level for yourself Level for yourself. You're good at level four. Give yourself some compassion. You're fine. Susan. Remember you see your message of empowerment authentic Confident we can confident level five win-win. What's the opportunity here and from my level six seven came coach That was the opportunity and that saved me Trust and then you can go into your happy spot where you're authentic powerful resilient quickly closing So an example for us too much compassion we give compassion you win level four you give too much compassion You get compassion fatigue and then you go to level two and burnout then you're in that level one two, I'm so needy I'm so angry. I don't like myself. I don't like my patients and I'm not good at it. I'm exhausted So, how do you get out of that? Give yourself some win-win peace and calm breathe win-win this the opportunity What's the opportunity here and use that level four to backfill yourself? You're so good at it Susan, may you be free of fear and anxiety. You do that to yourself. It's a practice. I do that every night when I go to sleep. I do that. I start with myself. So then you want the 6 and 7, then you want the grants, then you want the talks, then you want to help, you want to create programs, you want synergy with others, you want to be your authentic self, you get yourself to 6 and 7. And you just, that is being. You want well-being rather than burnout, you get up to 6 and 7. And that's where you think connection, that's where innovation comes. That's where you just know. You don't have to explain yourself, why do you want to do this? I don't know, I just know. I'm in my intuition. Thoughts are all pre-programmed. Intuition is how you arrived. It's the beautiful part of the magnificence. It's the connection we have to every person in this room. You know, in yoga we say, this light in me sees the light in you. And I know many of you do yoga, the light in me sees the light in you. That is the connection. That is where we came from, where we're gonna go to. And then you want even more, then you go back to our purpose. Our purpose, my gosh, we have the highest purpose, the oath to help others. And we hook that with our. And for another talk, in what I've learned, there are these on the far side. The energy things that the practice that you do, the 10 things, is all you have to do, take one a day, practice it, being connected, 100% of your energy is where you decide to put it. Because if you put it all down there, you don't have anything left up there. And then these other things that can be positive or negative. And if you're down on, especially for us, if you're down on your purpose, health care, if you're burnt out, no emotion, that drags you down. So you want to have a good social network. You want to be in the environment where you belong. Diversity, inclusion, equity, belonging. And guess what? For justice. It's just to have people have that. That's not a gift from me to you. That's what it's all about. So as you go through the things on the far side, those six things, be careful you're not leaving there as well. Thank you. That was a great hour. That was a great hour. We're just after 8 o'clock, and so we'll stay around for if you have any questions, comments. But you're free to leave if you're going off to the next session. I want to thank all the faculty. Fantastic presentations. And I know that we all learned a lot.

advancing equity

inclusion for women

medicine

surgery

gender disparities

hand surgery societies

mentorship

sponsorship

unequal standards

biases