AAN LEADERSHIP ALUMNI NEWSLETTER: May 2020

LETTER FROM THE EDITOR, MARIANNA V. SPANAKI-VARELAS, MD, PHD

Around the globe, a combat like no other is shaping our societies beyond imagination and transforming by the hour our behavior, thinking, reactions, and interactions. The COVID-19 pandemic is pushing us to physical, mental, and emotional extremes, and more often than not, we are becoming overwhelmed and devastated by the lack of control. As physicians, we do work under stressful circumstances, but this unprecedented crisis further intensifies the well documented and pre-existing burnout of neurologists. We are left with few outlets amid social distancing and melancholy can rapidly settle in. It is time to pause, reflect, and prioritize our physical and emotional wellness by seeking out resources, routines, initiatives, and platforms that will keep us attentive to our wellbeing.

In this issue of the AAN Leadership Alumni Newsletter, we focus on the importance of maintaining wellness during the pandemic and beyond. We present, to our members, resources that have been developed by the AAN to encourage wellness as a lifestyle. Moreover, we examine the impact of the pandemic on the education of residents, fellows, and medical students.

We have a unique article featuring Dr. Correa from NYC, a neurohospitalist on the front lines in the worst affected area in the country. In his own words: “Each hour I grew in the capacity to empathize from behind a mask and share support with a gloved hand.” We are thankful to him and all our neurology colleagues for their heroic efforts to provide care under the most challenging circumstances.

The importance of wellness has been recognized by the AAN through the development of the Wellness Joint Coordinating Council (WJCC) that ensures that all AAN committees view their respective initiatives and programs through the lens of wellness. Dr. Odia interviewed Dr. Molano, co-chair of the Wellness JCC, who highlights the role of WJCC in helping members to adapt to change during crises.

Dr. Ramos-Platt interviewed Dr. Sarah Mulukutla, who became involved with the AAN’s wellness initiatives early in her career as a neurology resident. Her words are reassuring: “the wellness efforts by the AAN are a response to offer solutions to this helplessness, to give empowerment, and ultimately, lead to the health of its members.”

Medical education across the nation is disrupted by the pandemic. Allison Zhong and Nicole Matluck, second-year medical students at NYMS during their video interview with Dr. Deeb, articulate eloquently the changes occurring to their education. They share their experiences with their involvement with communities affected by the virus and their efforts to promote wellness and resilience among their fellow students. This crisis will mark their generation and their adaptability and positive attitude are applauded.

Dr. Miravalle, in his role as a medical educator, provides valuable insights as to how the pandemic resulted in a rapid shift in how training is provided to different groups of learners (medical students, residents, and fellows). He expresses the opinion that medical education might evolve and change in the process. Health care and medical education will likely adapt to a new reality in the post-COVID-19 era.

Dr. Deeb gives us a visual of the many dimensions of wellness and summarizes various interventions that different health institutions have implemented to enhance the resilience of their workforce. Our members are encouraged to share wellness resources provided to them at their institutions to maintain their wellbeing during the pandemic and beyond. Make wellness a priority, a purpose, and an obligation to yourself.

Last but not least, we feature an article by Joanne L. Smikle, PhD, who urges us to build resilience by recruiting our emotional intelligence and courageously move forward post-crisis. Joanne’s article radiates determination, hope, and optimism.

“….Oh, deep in my heart,
I do believe,
We shall overcome….”

REMEMBER! Official AAN Leadership Program hashtag #AANleadership

A HOT-SPOT PERSPECTIVE FROM A NEUROLOGIST WEARING A “MEDICINE HOSPITALIST’S HAT”

By DANIEL JOSÉ CORREA, MD, MSC

Saul R. Korey Department of Neurology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10467

1) What do your new assignments/services include?

Our neurology department’s redeployment started on April 2, 2020. This perspective is based on a clinical rotation ending the morning of Sunday, April 12. 

Pre-COVID-19, my clinical duties included neurohospitalist rotations and service time on our Epilepsy teams. More recently, as the volume of neurologic patients has dwindled, our teams were redeployed to help in the evaluation and supportive care of patients with COVID-19. I just finished a 12-hour night shift rotation as the primary “hospitalist” attending caring for a medicine ward of patients with influenza-like illnesses, most of whom were either persons undergoing investigation or confirmed positive for COVID-19.

Our ERs and ICU have been flooded, and more critical care support is required of the hospitalists and specialists on non-ICU floors. In addition to each individual’s chronic medical conditions, this floor work included management of respiratory distress, pneumonia, electrolyte disturbances, acid-base disorders, acute-kidney injuries, along with monitoring inflammatory markers for possible cytokine storm and co-management of portable vents on the floor without critical care and respiratory teams.

Our neurology department has colleagues supporting ED teams, e-consult services, an expanded stroke team (accepting strokes from other overwhelmed medical centers), medicine hospitalist services, and medical ICU teams as clinical support staff. In all of these settings, our cognitive framework about personal risk protection and PPE has had to adjust rapidly to shortages and collaborative planning to sustain PPE supplies for a long-term battle.

2) How prepared were you?

My time as a neurohospitalist provided some preparation for this type of transition, but much of this respiratory and internal medicine management work required pre-reading and preparation whenever I had time. Thankfully, we had support through consults with an on-call medicine hospitalist COVID-19 advisory team, along with our infectious disease and critical care colleagues.

Until I was on the floor, I was not prepared for the emotional struggle each clinical care provider would endure until I heard from friends with family members admitted to hospitals. Patients are alone in their rooms; families are at home isolated and afraid for themselves and their family members. They all need support, empathy, and honesty. As the attending physician, we had to support our physician assistants, house staff, and nurses through a stressful and unprecedented course of clinical management for each patient. At times you feel helpless and ill-equipped, and then you feel the resolve to rise-up, use your skills, and always remember to reach out for support from colleagues. Each hour I grew in the capacity to empathize from behind a mask and share support with a gloved hand. Caring words, attentive gaze, and listening are more crucial than ever in this brave new world of social distancing and pandemic health care.

3) What training, if any, did you receive? 

The Montefiore critical care and internal medicine departments stepped up, providing us with materials including suggested protocols and algorithms for the management of COVID-19-associated medical conditions. We were also directed to other education resources for non-ICU level critical care management, including webinars from the Society of Critical Care Medicine.

Friends and colleagues were also a considerable help sending me materials from other hospitals responding to this crisis (including but not limited to MGH, Johns Hopkins, University of Nebraska). Dr. Jessica Bunin and other team members from the Walter Reed National Military Medical Center’s Critical Care team have put together an excellent series of whiteboard talks covering key COVID-19 related medical management.

4) How did you handle your own patients’ ongoing issues?

As a neurohospitalist without an outpatient practice, I simply have had to transition my care to the new medicine hospitalist team now supported by neurology attendings. Within our department, we have transitioned to telehealth visits for all non-urgent outpatient services, and teams are sharing responsibility for each other’s subspecialty’s clinic patients. Many of our clinics have one physician available on-site for neurology “urgent” care visits when the patient needs a clinical examination or does not have access to telehealth visits due to technology barriers.

WELLNESS AT THE AAN – THE ROLE OF THE WJCC

The Wellness JCC serves as a conductor, while AAN committees orchestrate wellbeing in the AAN community.

By YAZMIN ODIA, MD, FAAN, MS

The Wellness Joint Coordinating Council (WJCC), simultaneous with the Equity, Diversity, and Inclusion JCC highlighted in the April 2020 edition of the Leadership Alumni Newsletter, was created as part of the Presidential Initiatives by Dr. Terrence L. Cascino in 2015. We interviewed Dr. Jennifer Molano, a member of the first Emerging Leaders Forum class and the co-chair of the Wellness JCC, to highlight wellness and WJCC efforts amid the COVID-19 pandemic.

What is the vision and role of the Wellness Joint Coordinating Council (WJCC)?

The Wellness JCC (WJCC) was a direct result of the AAN Burnout Taskforce and resultant landmark study that reported 60% of neurologists suffer from burnout. The WJCC is intended to “coordinate efforts across the major AAN committees in order to mitigate burnout and promote wellbeing.” Comprised of members of central AAN committees, “the Wellness JCC encourages each committee to view their respective initiatives and programs through the lens of wellness.”

For example, the increasing burden of ever-changing legislation and threats to reimbursement were identified as key contributors to burnout in neurology, and the Advocacy committee of the AAN focuses on reducing the legislative burdens, which subsequently can help to mitigate burnout in our members. The Wellness JCC also continues to generate tools for individuals and institutions to help mitigate burnout and develop healthy coping strategies. The AAN has even compiled tools and resources to endorse self-care for its AAN members. The Wellness JCC serving as “a conductor” while the individual “committees serve as the orchestra.”

One of the most significant projects the WJCC is overseeing “is updating the AAN.com/LiveWell site.” As members of the Live Well, Lead Well work group, several of the WJCC co-chairs and members also support “the Live Well, Lead Well Leadership Program, which is now in its third iteration.” Neurology Today serves as the publication center highlighting various aspects of wellness. “In addition to their “Off the Clock” feature, which focuses on activities outside of the medical field, Neurology Today also has published articles on programmatic ways to address wellness, including projects from some of our Live Well, Lead Well graduates.”

What is Wellness JCC doing during the COVID-19 pandemic?

While the priorities of the WJCC remain the same before and now during the COVID-19 pandemic, the AAN brainstormed ways to highlight updates on COVID-19, develop teleneurology tools, provide legislative updates, as well as promote self-care and wellbeing of members.

The WJCC also has brainstormed and highlighted ways to empower the AAN community. For example, Dr. Neil Busis is the Wellness JCC member serving as the AAN liaison to the National Academy of Medicine (NAM) Action Collaborative on Clinician Wellbeing and Resilience and provided NAM resources to cope with the pandemic. Drs. Jennifer L. Bickel and Richard Isaacson narrated a video titled “Wellness in the age of COVID” to foster wellbeing even during these unprecedented times. The WJCC partnered with the AAN Education subcommittees to generate resources for residents and other trainees. The WJCC also sought to promote great examples of wellness from various institutions, which are also highlighted in Neurology Today. Explore some of those articles and the AAN.com/LiveWell site.

At her local institution, where she serves as chair of the University of Cincinnati (UC) Faculty Wellness Advisory Council and the UC Medical Center Graduate Medical Education Resident Wellness Committee, Dr. Molano sponsors a series of facilitated discussions called “Connecting through Change.” These discussions start with meditation, then foster reflection by asking “What impacts you the most?” and “What is your biggest concern?” The psychological burden is just as high, if not higher, an impediment to wellbeing during this time of crisis. The discussion then changes the focus to wellbeing by inquiring about what participants are learning from this pandemic, providing tools for self-care, and encouraging all to ponder “what next step they can do to generate peace and wellness in themselves and others.”

What are the key messages the Wellness JCC wishes to send AAN members during this time of crisis?

While the circumstances may differ, we can all develop tools, strategies, and partnerships to promote self-care and resiliency in all times of stress. The WJCC remains focused on providing useful frameworks to address COVID-19 and other crises while helping members effectively adapt to change.

“Great leadership is key” to provide guidance, perspective, and transparent communication. As such, WJCC and the AAN are committed to endorsing and empowering great leaders through the AAN Live Well, Lead Well Leadership Program. Like all AAN leadership programs, the AAN Live Well, Lead Well program adapted its curriculum in light of the COVID-19 pandemic. The AAN Live Well, Lead Well was delayed and will be transformed from a two-day intensive program prior to the AAN Annual Meeting into a longitudinal virtual program with a much-anticipated reunion at the 2021 Annual Meeting in San Francisco.

We can affect change and wellbeing within ourselves and those around us. While external factors contribute, individual resilience and self-care techniques are vital in enhancing healthy coping strategies. Facilitate wellness in yourself by “a daily five-minute pause, meditation, or self-care activity.” Building community, especially in this age of “physical distancing,” helps avoid social isolation. The WJCC wants to remind all AAN members that “you are not alone!” the WJCC and AAN are here to support you.

Explore the AAN.com/LiveWell site for updates and additional COVID-related resources!

Spotlight on Alumni

The AAN Leadership Program Interview with Sarah Mulukutla, MD, MPH

Decreasing Burnout by Promoting Wellness: Be Vibrant, Healthy, and Feel the Value of Yourself and Your Work. The AAN can help.

By LEIGH MARIA RAMOS-PLATT, MD

Underlying career burnout is emotional exhaustion, de-personalization, decreased career satisfaction, and low sense of personal accomplishment.

In 2012, neurologists experienced the lowest career satisfaction and high percentage of burnout among medical specialties. This finding catalyzed the AAN to explore solutions to this trend. There was a neurologist shortage with increased demand, leading to more pressure to see more patients and stretching our bandwidth beyond what was reasonable. More than half of neurologists surveyed had at least one sign of burnout. Because of this, the AAN moved to prevent physicians from leaving the practice of medicine. If neurologists leave, then the burden becomes greater for those that remain. This burnout extends to neurology residents as well. Studies have shown that residents feel burnout sometimes more than their attendings. This means that they will start their careers already disenchanted by their work. Thanks to multiple publications, particularly from 2016 to 2018, the AAN has been able to move from burnout, a pathological state of the workforce, to wellness.

I spoke with Dr. Sarah Mulukutla about the American Academy of Neurology’s various initiatives to promote wellness.  Dr. Mulukulta’s active participation with AAN started in 2015 when she was selected to attend the Enhanced Resident Leadership Program. The same year she presented a poster on her intervention that involved yoga, conscious breathing, and stress management for residents. She soon joined the Burnout Task Force, and very shortly she became a member of the committee for the Live Well ELA.

Dr. Mulukutla has been a member of the Live Well, Lead Well Work Group since its launch in September 2017. She is the chair of the Neurohealth & Integrative Neurology Section and chair of the Live Well Experiential Learning Area (ELA) at the Annual Meeting.

Her insightful comments capture the emotional distress in our professional lives. She said: “As physicians, we experience sad and unexpected outcomes. With the culmination of external pressures, we don’t have time to process, discuss, or understand our role in changing outcomes. We are faced with situations in which we don’t have control but are affected negatively by these external forces. The wellness efforts by the AAN are a response to offer solutions to this helplessness, to give empowerment, and ultimately, lead to the health of its members”.

She continued by reminding that, “wellness” shifts the focus away from compromising our core values. It shifts the focus towards the desire of the AAN for its members to be “vibrant, healthy (physically, emotionally, and spiritually), and feel the value [of themselves] and their work.” By shifting our focus, we can re-identify with our core values.

The first Live Well, Lead Well Leadership Program, led by Dr. Jennifer Molano, was a multi-month program and has since evolved into a program of two slightly different focuses. The programs now led by Dr. Jennifer Molano and Dr. Mark Milstein train AAN members to identify and work together on solutions to improve the health of their communities. These leaders gain tools to navigate the “rocky road to changing the [pathological aspects] of workplace culture.” The programs start with arming its participants with knowledge of evidence-based interventions. Participants work on how to build community, techniques for stress management, and how to improve wellbeing.

Peer and mentor-mentee relationships are components of good physician health. When asked about this, Dr. Mulukutla discussed how the AAN has been encouraging the natural fostering of these types of relationships through getting involved with the organization. By getting involved with the AAN, we can “extend beyond our local community and [its problems] while serving a great purpose.” The AAN has created opportunities of developing bonds with other members—the various leadership programs, opportunities to be part of work groups, committees, subcommittees, Synapse communities, special interest groups, and advocacy programs. Especially with the leadership programs, developing leaders leave having both a peer group and a mentor. The AAN continues to explore formal support networks. “This is a work in progress,” Dr. Mulukutla commented.

She was asked about the dissenters of the idea that wellness should be part of the AAN’s agenda—both in programmatic development and as part of the annual conferences. Although the Annual Meeting was canceled this year because of COVID-19, we can look forward to activities from the Live Well ELA in the future. To those that feel we should just take on the work and not focus on our health, Dr. Mulukutla would like to “… invite them to attend a session. Any of them. And experience it. A lot of this is experiential. And this is the challenge that we’re confronting. This is a whole culture we’re trying to change. And I fully agree that our culture has been based on the science and the physiology and how we can address or cure disease by working on the molecular and the pathophysiological route. But one other avenue I’ll mention is the Neurohealth and Integrative Neurology Section, where we’re studying how emotional wellbeing and social connection—socio and economic conditions impact health outcomes. We see this in neurologists as well as our patients. This is the universal human phenomenon.

[We should be thinking about wellness] because we’re human beings and physicians, first and foremost. Our role as neurologists and researchers requires taking a step back from the prevailing culture that our job is only to address through the physical. And that we’re not going to be able to reach everybody. We do confront challenges. There’s a lack of funding for these initiatives and efforts. I think younger generations inherently are more exposed to this so they grow up feeling that way. But for the individuals who feel that the efforts are not as worthwhile as scientific research, my impression is that that’s a bias. And I would encourage everybody to be aware of that: to notice their own cognitive framework that they're approaching.

And if they can step outside that and just attend just one meditation session or breathing session or yoga session at the Live Well ELA, then they may be able to experience it differently with their body. And that’s what we hope moving forward. We hope, just by being the change that we want to see in the world by showing up, leading these sessions we’re recruiting people. And slowly the culture is changing.”

COVID-19: A MEDICAL STUDENT PERSPECTIVE

By WISSAM GEORGES DEEB, MD

On April 6, 2020, Dr. Wissam Deeb interviewed two medical students attending NYMC at the height of the COVID-19 pandemic. Allison Zhong and Nicole Matluck are second-year medical students who are copresidents of their school’s SIGN chapter. They discuss how the pandemic has affected their education, including shifting all their coursework to an online format. They are missing some components of their training including gross anatomy, but they emphasize the great diligence by which their school has been adapting and innovating. They discuss multiple initiatives, many student-driven, to improve wellness and maintain connectedness among the students. The discussion shifts to the unfortunate racially motivated incidents associated with the pandemic and its effects on the morale and wellness of the health care workers. Finally, the students contemplate the lessons learned from the pandemic and how they envision medical education and care changing.

Allison Zhong: We are both second-year medical students at New York Medical College and we are both SIGN co-presidents of our chapter at NYMC. This is how we started getting involved with the AAN and we both organized attendance to the conference last year. I was also a participant in the Live Well, Lead Well program last year.

Nicole Matluck: Like Alli said, we are both second-year medical students and it was really her participation that kind of spurred us to get a whole group of students to come to the conference in Philadelphia last year and we want our school SIGN chapter be a little bit more involved in the national organization.

Wissam Deeb: How did the pandemic affect you in your institution and what have you been doing to try to maintain the education? What has changed in your lives with the pandemic right now?

Allison: A lot of our classes have been moved online, indeed all our classes have been moved online. Clinical rotations for third- and fourth-year students have been moved to online classes as well. I guess as second-year students, for us specifically, we are a little bit less affected, because we only had a few classes that were dedicated to study for STEPs. Moving classes online was not as big of a change for us. I think one of the biggest that students in our area have been worried about has to do with whether the STEPs will be happening or not and how the pandemic will affect our upcoming rotations.

How have your third- and fourth-year colleagues been responding to the COVID-19 pandemic?

Nicole: The third-year students, even the second- and first-year students, were really trying and waiting to get in there and get involved in whatever way they could pretty much immediately from the time this started happening. People were like “what can I do to help, how may I help, what is there for us to do?” We have a lot of ongoing projects; I am unbelievably impressed by our students for taking the initiative to do all of these things. The fourth-years, I think, are feeling a lot of things, they missed out on a lot of celebrations, and it is such a momentous time for them that it has been lacking. I think, with the news about potentially graduating early, I am not sure how our school is handling that, but they are, from the students that I have talked to at least, the fourth-years are ready to get in there as soon as they can.

How have you been involved so far?

Allison: Just for context, we are in Westchester county [NY], which is the hardest hit area in the United States, so we have been needing a lot of student participation – all voluntary, of course. So, there have been several initiatives started by students in conjunction with the administration to help out with both telemedicine, with temperature screening at our drive-by sites, with reporting results to patients. So those are ways that our administration is trying to allow third- and fourth-years and also second-year students to get clinical experience and allowing us to be involved with our community.

Nicole: The different student leaderships at our school have come together and we have been having nearly bi-weekly meetings just discussing the problems that have arisen and what we can do to address them. Community service and volunteering have been a huge common theme in all of these discussions. They created this system where everything is posted, all in one place, and they have been sending out a daily email about volunteer opportunities. I feel like it is really coming from the students having the connections with the members of the community who are asking for help, then bringing them to the leadership organizations, and then the information is being distributed to everybody via daily emails, so people can reach out and say “hey, I am available and I want to do that.” I feel that the communication has been constant, and it is really coming for both sides.

Did the transition to only virtual interaction negatively affect your education?

Nicole: It is a yes and no, I think a lot of people were using outside resources and watching the lectures online, so this component has not really changed that much, but there were still smaller group sessions, like we had some gross anatomy components of gross specimens for our organ systems, this we are missing out on, as well as we have these 20-person small groups and I think that clinical problem solving is a little bit missing. I think that they have tried as hard as they could, and I am really impressed with the administration’s adaptation. We use Zoom a lot, they are trying to have interactive Zoom polling to make it a little bit more engaging like it would be in person. That being said, I think there remains some small things lacking, but I think we are doing such as good job. The school and the students have stepped up in so many incredible ways to have these outside activities, like we have all these Zoom meetings within our housing system across the classes, as check-in points, to try to have “social” interactions virtually. I am really, really, amazed at how much our community has stepped up.

Allison: A lot of schools now are putting more clinical exposure into the first- and second-years, and so our preceptor visits were cut short. We can’t do any of the standardized patient interactions that we would normally have; so those are some of the areas that we are feeling the effect a little bit more.

How have you been addressing medical student wellness during these stressful times?

Allison: I am on the Wellness and Resilience Committee and we have been trying to come up with ways to keep the student body connected with each other, since so many of our students have moved off campus since all the classes have been put online for the rest of the school year. We are trying to figure out ways that we can have social activities, virtually, such as virtual movie nights, virtual discussions with the mental health department have been really helpful, and communication with our administration and our faculty who have been really great about discussing our concerns. They meet with us every week to address anything that is stressing us out, whether it is academic or not. This has been really helpful. As part of the Wellness Committee we have been sending out a lot of resources to the students, letting them know what events are going on, what our administration is up to, what the mental health department is up to and how to contact them. Even, you know, one of our admin’s wives got involved in hosting cooking classes, which I think have been really great.

Nicole: We also have, at our school, weekly yoga classes, that they are still hosting via Zoom and we have a housing system that has been doing virtual happy hours together – kind of like COVID-free talk, so that we can take an hour of our day to not be constantly bombarded with it. I think this is helping ease some stress for some people.

Incidence of racism associated with the COVID-19 pandemic

Allison: I guess for me this has been a really salient topic just because I am Asian-American and so I am following a lot of the news and the things that are happening to people around the country and around the world who look like me. I think one the biggest things that has impacted me was seeing in the news and hearing from people I know about specifically health care providers who are buying into rumors and a lot of racial biases that is around COVID. Just as an example, we all saw the New York Times article about the PPE situation – one of the points of the article was a text from a physician that basically was yelling at the doctor and calling [COVID] the Wuhan virus. There were a lot of issues going on here, but one of the issues that stood out to me was the fact that they were using terms that are racially motivated. I think for me that was something that is fundamental to wellness, where you are affecting the mental health of your health care workers because they have the added stress about attacks like that and about physically violent attacks that have been happening around the country. They have to worry about that for themselves and for their families, which has been more detrimental to their mental health. For me
personally, my dad lives in Texas and he saw a news article about a Chinese American family who was stabbed in the grocery store. One of our topics was about trust between colleagues and how colleagues should respond to each other in racially motivated situations. We had a scenario of a racial incident in a clinic and we were talking about the appropriate actions that the colleagues should take to protect the person targeted by the racial incident.

What can we learn from this pandemic?

Nicole: Just with the experience of how much and how quickly we had to adapt to moving everything virtually and so far, how relatively successfully things have gone, I do see this more of a trend going forward, both with medical school and telemedicine in general. I know that some of that infrastructure already existed, but especially for certain outpatient things I see as going pretty far and I think it will have really important benefits for the community especially rural areas that don’t have access to health, having an internet connection is in some places all you need to improve medical care. I think that we will try to further implement [tele-education and telemedicine], at least, I hope. I also think we are now more aware how almost unready, some of the places were not ready to deal with this, and I don’t know if anybody could have predicted if something to this extent could have happened right now, but I think or I hope it will help for future preparedness in people. There is a lot to be said about the wellness of residents and interns as well going through all of this and having to deal with all of this right now, so I hope it will improve the way we all treat each other and the lives of our interns and residents and colleagues going forward.

rethinking medical education during a pandemic and beyond

By AUGUSTO MIRAVALLE, MD, FAAN

Even though pandemics have been documented since antiquity, they still present unique challenges to medical education. Most institutions follow the pedagogical philosophy that medical students and residents are considered “junior doctors”. Hence, their active participation in the care of patients during a pandemic could provide valuable medical training. On the other hand, one would argue that the learner’s active participation in the care of a patient with COVID-19 is solely intended for their educational benefit, rather than the provision of care for the patient, and the risks to their health might not outweigh the benefits. These decisions should be made on a case-by-case basis taking into account the level of training of the learner as well as the perceived need for supervision in the care of patients. As an example, the ACGME dictated that, effective immediately, all fellows will be allowed to act as attending physicians should the institution need them to meet patient care needs, using up to 20 percent of each academic year. Beyond the curriculum needs of their training, it is also important to consider the learner’s sense of wellbeing.

Moreover, the implementation of mitigation measures such as mandatory social isolation have resulted in the need to formulate contingency plans to promote the development of clinical competence without the contact with a “live patient”. As an example, previous experiences with the SARS outbreak resulted in a rapid expansion of online resources, including the use of patient surrogates, e-learning modules, flash multimedia, simulations, and virtual patient encounters. The ACGME is encouraging programs to provide continued education to residents/fellows, when feasible, utilizing remote conferencing technology, webbased resources, and other innovative tools. Pandemics could also pose a unique challenge by interrupting longitudinal assessment of competencies, necessitating the adoption of innovative telephone-based assessment tools, modified essay questionnaires, and online chat rooms. As announced on the March 18, 2020 ACGME Letter to the Community, faculty members are allowed to provide direct supervision and assessment through telecommunications technology without penalties. The ABPN is also allowing Program Directors to use virtual clinical skills evaluations. The following links provide more details about the response from the ACGME, ACCME and ABPN to COVID-19:

• https://acgme.org/covid-19
• https://acgme.org/COVID-19/Frequently-Asked-Questions
• https://www.accme.org/covid-19-educator-resources
• https://www.abpn.com/wp-content/uploads/2020/04/ABPN-Accepts-Virtual-CSEs-announcement.pdf

Ideally, there is no better teaching tool than spending quality time with a learner at the bedside of a patient. In the event of a pandemic, however, it is reasonable to rethink our approaches and consider the utilization of technology and patient surrogates. It is also vital to continuously and actively involve our learners in the care of patients, allowing them to contribute to patient care whether this is through telehealth and/or remote clinical care. The magnitude of this current pandemic might result in significant and permanent changes in the way we practice medicine. Likewise, medical education might evolve and change in that process. Perhaps it is time to consider proactively developing innovative approaches to educate the next generation of leaders in neurology who can smoothly adapt to evolving and challenging health care environments for the foreseeable future.

creative wellness initiatives at institutions

The coronavirus pandemic has quickly altered our lives. Even if not directly infected, uncertainty, people suffering or dying, and social isolation elicit fear and anxiety. Hence, this pandemic is affecting our health in direct and indirect ways. The World Health Organization’s constitution defines health as “a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity.” This state of wellbeing defines wellness, a goal we aim to achieve internally, with family, at work, and with society at large. When thinking about our wellness, it is essential to remember the different dimensions: mental, physical, psychosocial, and occupational.

Multiple institutions are offering their employees different resources to improve their wellness during these stressful times. For mental health, resources such as crisis lines and support groups have been expanded and made available for free to staff and physicians. Many of the resources have switched to a telehealth format to improve access and reach. Mental health tips are more frequent in our inboxes, reminding us to spend a “wellbeing moment every day,” such as stretching, breathing exercises, or reading an encouraging quote. Where and when permitted, going outside and preferably into nature

can provide a mental health buffer. The breeze on the skin, the feeling of grass under the feet, or simply soaking up the sun can have healing effects. Similarly, guided-meditation videos are a valuable addition. Second, exercise and fitness classes have moved online either in the form of pre-recorded videos, live events, or online challenges. Myriad exercises are now available such as yoga, revitalizing flow, and 13 aerobics. Due to social isolation and home confinement, particular resources have been developed to improve psychosocial wellbeing. Virtual meetings and impromptu e-get-togethers are helping to relieve some of the “cabin fever.” Socializing is a basic human need that cannot be ignored. The wellness programs at different colleges and institutions have proposed multiple ways to socialize while maintaining social distancing precautions. These suggestions include video chatting, hosting a Netflix party, online multiplayer games, doing a craft together using an online platform, playing charades online, and many others. Furthermore, many universities and cultural centers are broadcasting concerts, operas, movies, and other shows for free to the general public.

Finally, feeling safe while performing our job duties is paramount to a sense of wellbeing. Ensuring a clear message from leadership that the employees are heard, and that safety is paramount can significantly improve wellbeing. For example, some organizations are providing their front-line workers a free hotel room for rest and revitalization following their tiring work hours and shifts. In a recent viewpoint published in JAMA Shanafelt, Ripp, and Trockel review the sources of the anxiety of healthcare professionals, their requests, their concerns, and the expected responses.

What are the resources that you are using to help improve your wellbeing and wellness during this pandemic? Please share in Synapse using this link. More creative submissions, such as short essays, poems, pictures, or paintings, may be highlighted in upcoming editions.

We thank the wellness committee at the Albany Medical College and Center, the faculty and staff assistance program at Emory University, and the wellness program at the University of Florida for their contributions to this article.

consultant corner

Building Resilience
By JOANNE L. SMIKLE, PHD

We keep hearing the word resilience in the midst of this pandemic. Let's be clear on what resilience really is. It is closely tied to emotional intelligence in that it requires high levels of self-awareness and self-management. Resilience is the ability to rebound from misfortune, crises, adversity, frustration, and disaster. This may seem counterintuitive---how can we possibly think about rebounding while amid the Creative exercise routine by spelling your name – courtesy of the Wellness Program at the University of Florida. 14 storm? Hopeful, forward-focused thoughts are essential. Without the optimism that accompanies resilience we will be overcome by the anxiety and despair of our current situation. Not only do physician leaders need the highest levels of resilience, they must model it so that others emulate their behavior. That's tough but definitely doable.

No doubt, we are now challenged with being more resilient than we ever thought possible. It is even harder when we don't know how long we will be in this trying situation that requires so much fortitude. Shifting energy to an intentional focus on resilience enables us to survive, with the goal of thriving. Yes, thriving...resilient people are able to move beyond their prior levels of functioning and grow as a result of adversity. They have the emotional intelligence required to reflect during the crisis to learn more about themselves, the nuances of their crisis response patterns, and to use those insights to purposefully move forward. This reflection also provides the opportunity to hone leadership skills and messaging competencies. Thriving will entail leading more effectively and learning to communicate compelling messages that inspire others.

We need resilience so that we can recover as individuals, organizations and entire healthcare systems. Here are three strategies that you and your team can use to build a reserve of resilience.

3 Strategies for Facing the Future:

1. Intentionally Plan on Moving Ahead... Create a mental plan, commit it to paper, for moving forward post-crisis. Being intentional about building a positive future refocuses your mental energy. It will open ideas and options that you never considered. If you invite others into your future-focus you will be modeling effective crisis response strategies.
2. Intentionally Plan on Adapting... Fear of change, mourning the past, and denial keep us from both creating and adapting to a "new normal." Why not use your energy to identify ways that you can adapt to evolving situations? Consider helping others discover ways in which they can adapt. Adaptation is the healthy choice that reduces the frustration of fighting a losing battle to live in the past.
3. Cultivate Courage... Use your inner strength to face the future, face your fears, and move forward. Courage is a muscle; the more you use it, the stronger it becomes. Use the courage of your convictions to build a greater resilience reserve.

Resilience is among the most important skills that we can develop during adversity. Use these three strategies to develop the capacity to bounce back and create a future full of positive possibilities. Resilience is our best option in adversity.

Joanne L. Smikle, PhD is a respected authority on leadership and organization development. Her consulting practice serves clients across the country. Read more of her insightful work at smiklespeaks.com

Leadership Development Committee Vision and Mission:

Vision: All members will achieve their leadership potential.
Mission: To cultivate and inspire leaders in neurology and foster their engagement with the AAN

Editorial Team

Editor

Associate Editor

Contributors

We hope you have enjoyed this issue of the Leadership Newsletter.

Marianna V. Spanaki-Varelas, MD, PhD

Editor

SUPPORTERS OF THE AAN LEADERSHIP PROGRAM

ACADIA Pharmaceuticals, Inc.

Acorda Therapeutics, Inc.

Alexion Pharmaceuticals, Inc.

The Allergan Foundation

Allergan, Inc.

Biogen

Eisai Inc.

Genentech, Inc., a member of the Roche Group

Greenwich Biosciences, Inc.

Lundbeck, LLC

Neurocrine Biosciences

Sanofi Genzyme

Supernus Pharmaceuticals, Inc.

UCB, Inc.

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