In this presentation, we will take a look at multiple choice questions related to budgeting, going through the questions, and then practicing test taking skills with them. First, a word from our sponsor. Yeah, actually, we're sponsoring ourselves on this one because apparently the merchandisers, they don't want to be seen with us.  Like our Accounting Rocks product line. If you're not crunching cords using Excel, you're doing it wrong. A must-have product, because the fact as everyone knows of accounting being one of the highest forms of artistic expression means accountants have a requirement, the obligation, a duty to share the tools necessary to properly channel the creative muse. The muse, she rarely speaks more clearly than through the beautiful symmetry of spreadsheets. So get the shirt, because the creative muse, she could use a new pair of shoes. If you would like a commercial-free experience, consider subscribing to our website at accountinginstruction.com or accountinginstruction.thinkific.com. First question, budgeting process usually ends with, A, budgeted financial statements, B, sales budget, C, production budget, D, cash budget, E, an argument. Let's go through this again using the process of elimination. Budgeting process usually ends with, now whenever you see a question like this and you will see them when you're dealing with budgets, because we have to make the budgets in some kind of sequential order. We just try to dive into some component of the master budget without thinking about it in a process-type fashion. It'll be a mess. So we've got to do it in order, and so we're visualizing the order. So we're looking at the end of the order. What's the last thing that's going to happen with this budgeting process? A, the budgeted financial statements. That sounds pretty reasonable, because after you go through this whole thing, you can have a balance sheet and income statement you would think that would be budgeted, but you think the balance sheet and income statement will be. So I'll keep that for now. B says the sales budget. Now the sales budget's got to be one of the first things we do, because we can't do much else until we figure out how many units we're going to sell, because we can't budget too many other things until you know that. So I would think that would be somewhere towards the beginning of the process. C says the production budget, and the production budget, you're going to need that somewhere up there, somewhere towards the upper, middle-end type of area, because you need the production budget to know how much you're going to spend, you need to know how much for your cash flow budget and whatnot. So I don't think that's it. D says the cash budget, and that's towards the end. So maybe we'll keep that for now, because we've got to do all the other stuff before all the times we can do the cash budget. And then E says an argument. Now the arguments hopefully happen during the budgeting process, and by the end of the budgeting process, you have squashed or reconciled or at least moved on from all arguments, you would hope. So we're not going to be E. We're going to be less with A and D. Going through this again. Budgeting process usually ends with A, budgeted financial statements, or D, cash budget. Now of those two, you would think that the financial statements I would think would be after the cash budget. The cash budget would be towards the end, because you would need to know other things to get to the cash budgets, the flow of the cash. But the financial statements are typically what we would consider the end result. When you think of a budget, we're usually thinking about the income statement a lot of times. We're trying to get that income statement into the future, the timing accounts, the performance accounts. But we also will have where we will be at the end of that time period, at the end of that year, and that will be the balance sheet. So I'm going to go with A final answer. Budgeting process usually ends with A, budgeted financial statements. Next question. The starting point for a master budget is estimating A, expenditures, B, cash receipts, C, production, D, sales, E, cash payments. Let's go through this again using the process of elimination. The starting point for a master budget is estimating. Now again, we've got to visualize what the process is going to be. We've got the master budget. We've got to go through all the budgets kind of in order. We can't just jump in the middle and start budgeting things. It's got to go from a beginning point to an ending point. Otherwise, it'll be a mess. So what we want to have that visualization in our head. A, it's going to start with the expenditures. Typically not, because you would think we're going to start somewhere around kind of like you would think of the income statement, which starts with revenue, right? The sales type. We've got to start with the top line, not the middle area. So not expenditures. The cash receipts. Now you might say, cash receipts. That seems like a good place to start because that's at least the money coming in. C says the production. And you might consider that as we need to know how much we produce that somewhere towards the top. So I'll keep it for now. D says sales. And that's the top of the income statement. So you would think that sales like revenue would be somewhere up there. And then E says cash payments, which is kind of like expenditures. I mean, it's kind of like, we would think we would need the receipts first before we consider how to budget the expenditures possibly. So I'm going to eliminate that one. We'll keep B, C and D go through this again. The starting point for a master budget is estimating either B, cash receipts, C production or D sales. Now of those three, I would think it would come down to basically cash receipt or sales before production. And then cash receipts and sales of those two, we're generally going to go through the sales first because we need to basically know what the sales are before we can consider what the cash receipts will be. So usually the sales then we're going to have to at the top towards the top of the starting point of our budgeting process. Final answer, the starting point for a master budget is estimating D sales. Next question. The master budget process ends with A, the production budget, B, the sales budget, C, the selling expense budget, D, the budgeted balance sheet, E, the general and administrative budget. Let's go through this again using the process of elimination. The master budget process ends with A, the production budget. So the production budget you would think would be somewhat, we're imagining the level of, it would be somewhere at the top, you would think, because I got to know how much stuff we're going to produce out of things and that's not what we're going to, that's not the ending point. B, the sales budget. Now that's one of the very first things we need because we got, it's not where we're going to end. That's where we begin. C says the selling expense budget, yeah, it's probably somewhere in the middle. I don't, that doesn't seem like the ending point. It's not like the finale, the selling expense budget doesn't seem the finale last thing that we'd, I don't think it, D says the budgeted balance sheet.  I'll keep that one for now. E says the general and administrative budget. Again, not very, that doesn't sound very, you know, the finale type in thing that we want to get to. Sounds kind of, kind of blah. So I'm going with D on this one. I'm going with the final answer. The master budget process ends with D, the budgeted balance sheet.


It's now been four months into my cardiology fellowship and today I wanted to do a deep dive into how it's going, the positives, the tough points, my schedule, my current goals, and if I ultimately think that I made the right move going from being an attending all the way back to training. Let's get into it. Hey friends, welcome back to channel. In case you're new here, my name is Lux. I'm a board certified internal medicine physician and currently a brand new cardiology fellow. Now this definitely has the potential of being a longer video and episodes. If you're interested in a specific part that we'll talk about, I'll link those down below in description. But as a little bit of a background in case you're not familiar with my story, I graduated medical school back in 2019 and then did three years of internal medicine residency. Then after my three years of residency, I basically had a choice. Do I go to further training to be a sub-specialist like a cardiologist or do I go ahead and just work as a general internal medicine doctor as something like a hospitalist? Ultimately where I was doing medical school and where my family and my wife are from are two different cities. We made the choice of moving back home just to be close to family and making a decision while I worked as an internal medicine hospitalist for one year. If you wanted to see what my day in the life as a hospitalist looked like or why I picked the field of internal medicine in the first place, I'll link down below those episodes down below. But during my first few months of being a hospitalist while I enjoyed the job and the schedule because I would have every other week off, I also realized that it wouldn't be something that I would be able to do for 10, 15, 20 years and come to work with the same level of excitement. And so that's why with the support of my wife, we made that decision to go ahead and apply for fellowship, which is what I did back at the end of 2022. And right around this time in November of 2022, I figured out that I matched or basically got into the program of my choice to become a cardiologist. Now at this point in November, I knew I was going to start fellowship but it wouldn't start until all the way until July of 2023. So I went ahead and worked the remaining months between November and June to still be an internal medicine hospitalist. And then come July of 2023, I ultimately transitioned from being an attending where I was making all the decisions myself without any supervision to now being back to the trainee as a cardiology fellow. Now while it sounds fancy, a cardiology fellow is basically somebody who's training to be a cardiologist. Cardiology fellowship is three years. And this is my first of my three. And it basically means that on every rotation on every patient that I take care of, there's always a board certified cardiologist who's working with me and overlooking my decision making. And if I have any questions, that's who I go to. So that was back in July. And now as I'm making of this episode, we are officially in November or four months into fellowship. So I'm going to break down essentially what I've done so far, what my schedule looks like, what my role has been on all these rotations, my upcoming schedule, and then also talk about some of the pros, some of the cons, as well as ultimately, if I feel like they made the right move of going from being an internal medicine hospitalist to now becoming a cardiology fellow. So first, let's talk about my schedule for my first four months. So my first month as a cardiology fellow was actually a mixture of an orientation and a boot camp. Now this format of having a boot camp for a month is actually not typical at all. Usually when you start fellowship, particularly a cardiology fellowship, you may do a week of getting your badges and getting credentialed at various hospitals and clinics you have to work at. And then they just kind of throw you in. So you may be within your second week of fellowship, working in the cath lab or seeing consoles as a cardiology fellow for us at our program, they actually nicely ease this through and that each week had its own theme. The first week was made to do admin kind of credentialing. The second week was meant to just learn basic things in ICU. Third week was meant for cath lab. And the fourth week was meant to learn some skills in the echo lab. Now again, this is usually not typical, but I did appreciate this kind of system that my program created because it allowed you to jump into fellowship without the nervousness that usually comes with it. And while I was excited to go through this boot camp, I knew that my wife at that point who was about 36 weeks pregnant could be due at any point. And while we were originally expecting her to come at the first week of August, she actually came a few weeks early, essentially two and a half weeks into my cardiology fellowship. Now thankfully my program allowed me to make some adjustments to our schedule, especially because the boot camp wasn't as essential. And I was able to go on a paternity leave slash elective research rotation. So during that last two weeks of July, I was essentially at home learning cardiology to the best of my knowledge while enjoying time with my brand new daughter. So as a month of July, now we go into the month of August, which was my official first month as a cardiology fellowship. I'm coming back from paternity leave and I don't know anything. I feel like I've been missing out because all of the other fellows have gotten experience to the echolab, the cath lab. I don't feel like I know any cardiology. So my first rotation was actually in the congestive heart failure rotation, which is the CHF rotation. This is something that I felt like I did before in residency. Often you're taking care of patients who come in with what we call bread and butter heart failure. This is the people who are short of breath because their heart doesn't squeeze very well. So they tend to accumulate fluid in their lungs and the rest of their bodies. Now pretty much any medicine doctors should feel comfortable taking care of heart failure exacerbations. But in addition, in the CHF rotation, we're also taking care of more complicated patients such as patients who have had a recent heart transplant or patients who have things and devices such as LVADs. Now an LVAD stands for left ventricular assist device. Essentially in heart failure, a left ventricle, which is the muscle that is made to do all the pumping from your heart into the rest of your body. If for some reason it's not working and you're not eligible for something like a heart transplant, an LVAD is basically a pump that sticks to that bottom part, the apex of that heart essentially will take blood out through a vacuum and send it to the rest of the body so that pump doesn't have to work as hard. Now being familiar with these devices as well as the complications that come with them really takes a little bit of training. Thankfully I had some exposure during residency to these devices. So during this rotation, I was also managing patients with LVADs. Now we get into my second official rotation, which is the month of doing echoes. This probably felt like the most cardiology thing I had done at this point because when you read echoes, especially as an internal medicine hospitalist or resident, you're usually kind of looking at the report or the basic images that you're just kind of taught to look at. But now as a cardiology fellows, I was actually submitting the report in addition with my attending on things like their heart function, their valve function, and more information. So all the things on the report are things that I was doing. Now usually the way this rotation was set up is that the first half of the day was really meant for me to read independently and at my own pace. So the echo text would be scanning patients across the hospital. It'd give me a text when a next patient was ready. And I would go ahead and start reading through the report and submit kind of a preliminary that my attending would then see in the afternoon. This is where I got a lot of my numbers in terms of reading echoes by myself. And then every afternoon there would be a different attending assigned to read echoes for that hospital. And then together we would go over the echoes that I read earlier parts of the day as well as the new ones that came in the afternoon. This was honestly such a cool experience. It definitely felt like more like a radiology elective or rotation because we weren't dealing with patients directly, but just learning the nuances of the measurements and how to look at the pictures that have been used to doing for the past four years. But now truly as a cardiologist again really made me feel like, okay, now we're making a different career move before I was taking care of heart failure patients that I did as a hospice. This definitely felt like a different element of clinical medicine that I've never been exposed to before. Next is my third rotation, which is also the next behemoth of cardiology, which is working in the cath lab. Now working in the cath lab is the field of interventional cardiology. Imagine if somebody comes in with a heart attack and somebody puts in the stent. That's what an interventional cardiologist does. But often we also do things like diagnostic left-hard cast or coronary angiography, which is essentially just fancy words for saying, let's look to see how your heart vessels, those important arteries of your heart, if they're open, if there's any blockages, if you're having chest pain, if a blockage is explaining that or if they're completely open, then we need to look for different causes. Now this rotation specifically had me really nervous. One, I had missed a lot of the initial boot camp and the introductions that other fellows had gotten, so I already felt like I was starting behind the eight ball. And you would often show up and not only do you not really know these procedures, you've never done them before, but every attending has their own styles of what catheters they use and how they do their own procedures to ultimately get their same results. It's my first week on the rotation, I really felt like a complete noob not knowing how to get access, how to use certain things, how to just kind of behave in the cath lab, because it's almost like surgery where everyone's gowned up, you have to keep yourself clean, you kind of have to know where your hands need to be, how to make sure you're taking care of the patients, and avoid obviously not causing any complications. But after my first week kind of understanding how to do the step by steps of all the procedures that everyone would be doing, I finally started to get the hang of it, I think, and by the end of the rotation, I was able to do procedures like a left-hard cat and definitely like a right-hard cat without my attending really being involved at all. If you're interested in me diving more into these procedures, let me know in the comment section down below. But a left-hard cat is probably one of the procedures that you do the most in the cath lab, often you'll have patients who are admitted in the hospital for things like chest pain, maybe they have a shraponin, which is an enzyme that usually represents some kind of heart stress or heart damage, and then you may be getting a referral to do a left-hard cat in that patient. Often we'd go either to the wrist or the artery in the groin and you would get access either through an ultrasound or sometimes blind. That was cool, learning how to do that anatomically, and then after you got access by advancing a catheter, you would then use that access point to advance wires and catheters all the way down the sending aorta right above the heart, and you would use those to engage the coronaries, the left as well as the right. And this is honestly probably one of the hardest parts of the rotation, is you just have to memorize these tiny steps that ultimately lead you to doing the entire procedure.  The second hardest part is what we call engaging the coronaries. Once you get your catheter there, the idea is for you to be able to shoot contrast while the catheter is in the left coronary artery or the right coronary artery, so you can get pictures like this. But as you can imagine, these arteries are not big and you can't see them under the x-ray or fluoroscopy that you're using in the cath lab. So you're using a combination of both experience and anatomy to maneuver and rotate the catheters in certain orientations where you think the left or the right coronary may be. And when I first started, I by no means had the experience to really understand how to make these small movements, but again by the end of this rotation, I was overall able to get into the left coronary, get into the right coronary for most of my patients. Now just to give you some idea of how involved I was as a fellow, this rotation was four weeks, but one of them for me was a week of vacation. So for three weeks in the cath lab, I easily scrubbed in and participated in over 60 procedures. Most of them, which I was pretty hands-on. And they're my first year as a fellow. We spend anywhere from two to three months in the cath lab, so they'll easily lead to 100 to 200s of cases and again extrapolate that over the span of two to three years of fellowship. I'll definitely get my repetition and bearings in the cath lab. And that finally brings me into my current rotation, which is a month of cardiology consults. Now this is basically a month of me working one-on-one with the attending, taking consults from the teaching team so whenever they feel like they have a cardiology patient that they would like us to help them make decisions on, they would let us know through a text or an email, and then the next morning we would see those subsets of patients. And during a typical day, I'll see a combination of patients that'll come in for chest pain, shortness of breath, bread and butter, heart failure, arrhythmia, as well as a lot more. And overall this month has probably been the most similar to my life as an internal medicine hospitalist, where again, the patient comes in with a specific complaint and my job as a cardiologist now is to help with that specific complaint. It's also been a good month for me to just flex my cardiology muscles as well as identify things that I just don't feel comfortable with using the help of my attending. Now the hardest part of this rotation has simply been the coordination aspect. As a cardiology fellow, at least in my program, our role is really making sure if somebody needs a procedure, then my job is to make sure it's coordinated, understand what time it's done, make sure all the orders for that patient as well as their consults are in, and that's just a lot to do in addition to all the notes you have to write for the consult, plus all the rounding you have to do with your attending as well as that teaching team. Now that's a breakdown of the four months that I've gone through so far, but let's quickly talk about my upcoming schedule for the rest of my first year fellowship. Now after this month of consults, an exportation that I'll do will be a month of doing nuclear imaging, so that includes just kind of looking at things like stress tests for patients who come in with chest pain. After my month of nuclear medicine, I'll be doing a month in ICU where I'll basically be managing the units of patients who are super sick with things such as post-transplants, cardiogenic shocks, arrhythmias, bradycardia, syncope, you name it, as well as patients on really complicated advanced supports. People who are on balloon pumps and pelas, ECMOs, there's a lot that'll go into it and I'll definitely make a different episode on that all together once I get there. After my month of ICU, I follow that up with another busy month in the cath lab and then lighter month on doing echoes. And then I'll wrap up the year by doing a month of electrophysiology or arrhythmias of the heart, and finally another month of ICU to wrap up my first year of fellowship. Next I want to talk about my average daily schedule using those first four months and those rotations as an example. Now the individual scheduled will vary depending on the rotation, so in cath lab I was showing up at seven o'clock because sometimes the first cases were at seven thirty, but usually my start time will be anywhere from seven to eight a.m. in the morning. And in terms of when my day will end, usually average is from four to five p.m. and most of these rotations that we talked about also have weekends off, which is super, super nice. Now finally as a cardiology fellow, we do one overnight in-house call in the ICU. This basically means that if I'm on call like I am this week on Tuesday, I would do my rotation in consoles throughout the day and then come forward at five o'clock. I would take over for the day ICU fellow. I would stay in the hospital, we have a call room that we can use, and I basically make sure that if there's any new patients that get admitted to the ICU, those would come to me. If there's anything that happens to one of the day patients, I am basically responsible for that call and managing them. And I basically stay overnight to make sure that there is at least some cardiologist there to take care of these sick patients. And the next morning when the day team comes, I'll make sure I tell them about the old and the new patients, and then I get to go home. Now initially I was nervous about this format of having an in-house call, especially having a new baby at home, feeling a little guilty of leaving my wife with her now four month old. But overall it's worked really nice because the day that I go home, I have that rest of that day off. So if I managed to get any sleep during the night, I can usually just push through that rest of the day and enjoy time with my daughter and my wife. Now while most rotations will have the weekends free, there are some rotations like the cath lab or ICU at my institution where your call day will be on those specific days and thus you'll work an average of six days a week instead of the average of five. And then finally the only other aspect of my schedule is every Monday afternoon I have an afternoon of continuity clinic. This is basically patients that I have added from panels from prior fellows as well as patients that I may see in the hospital saying, how about you just follow up with me? My clinic is closer, if you don't have insurance, but we take your insurance. I basically follow these patients for the duration of my three years. Now if you enjoyed that breakdown of my daily schedule and you want to see what my morning routine looks like as a cardiology fellow, especially as having a brand new baby in the house, go ahead and check out the episode which I'll link down below with my full morning routine. And then finally to close off this episode, let's just talk about my experience, the good and the bad, especially the most important question, which is, do I feel like I've made the right decision? Now number one, I realized that I just absolutely love cardiology knowledge-wise. Like I really can see the practicality of what I learn with matching with my interest. I wasn't always the case as a hospice where I'd be learning about things like inhalers or medications or rheumatology, when those wouldn't be in the fields I was necessarily interested in, but I would have to learn it to take care of a patient better. Number two, I really did feel like I selected a great program, obviously a fit geographically to being close to our families, but I do feel like I'm in an environment where I don't feel like I'm in a toxic environment. The people and the program leadership and the tendings that I work with really do see me as somebody they want to teach and kind of mold into a better cardiologist. My co-fellows are amazing, very laid back, and again I come to work feeling like I'm a better cardiologist without the pressure of being a cardiology fellow. I really do appreciate that. Number three is I'm surprised at how much exposure and autonomy I've gotten just four months in. I was really nervous about, especially when you're a brand new cardiology fellow, it's really normal, especially when you're in med school and residency where people at the top, the intending in particular, they will say, well let's not let the med student or the resident do that. But as a cardiology fellow, I felt more often that I've gotten a lot of permission or green light to just make calls and let's see what happens, especially when I'm in-house in the ICU, if there's a patient who's crashing, a lot of times I will make a decision, a lot of that also comes from my ability to feel comfortable doing that as a hospice. And in text my sending saying this patient was not doing so well, these are the things that I did or the orders or tests that I've ordered. And often my attending will kind of give me a text message with a thumbs up and maybe some additional thoughts that they feel like I missed something. But those messages and response and just the ability of making a call allows you to have some confidence in terms of taking care of patients. If the decision you make may not happen, the best one that you'll learn through that experience and then be able to do that better for a future patient. Number four is I've been surprised that the schedule has been much nicer than I expected. Now this is definitely going to change when I work in the ICU in about a month or two or I'm going to be working long hours and also working six days a week, that one's going to be rough. But more often than not, I've been surprised of having my weekends off like I do right now. I've been surprised of how early and not as late as I was expecting to come home and just having that balance of being a dad, being a husband and also being a cardiology fellow while creating content for you guys. It is definitely harder compared to being a hospice where I had every other week off. I don't find it as hard as residency, which is what I was expecting. Number five, the teaching that I've gotten from my attendings, my co-fellows, where a few years ahead of me has been just amazing. A lot of the format at our specific program is really one-on-one. So it's me and the attending, me and the attending of the cath lab and the echo lab. There's just a lots of learning that they fill in, the gaps of knowledge that I may have and I have tons of them, but I don't feel like I'm competing for their attention as I may have to as a multitude nor a resident. So the amount of learning that I've gotten in a short amount of time has just been extraordinary. And then finally, number six is probably the only, it's not even a con, but it's the biggest surprise that I've had in terms of the negative is that self-learning in terms of self-learning cardiology has been a lot harder than I imagine. Big shift from residency where there's always education going on and there was surprising enough time to just learn new medicine. As a cardiology fellow, especially as a being a new dad, and I think that's a big part of it, is I show up to work, I do the clinical duties, I try to learn as much as I can for the gaps that I have, but there's not like this 20, 30 minute slot where I can read about the next topic in cardiology to where I can just feel like a better fellow. There'll definitely be a requirement for me to build better systems on a weekly basis where I'm going and reading journals or listening to podcasts. I'm definitely adapting those, but I was expecting to have more time on a weekly basis to kind of expose myself to the next topics in cardiology that I still haven't mastered. Right now it's kind of been feeling like learning on the job, which again is completely okay and completely normal, but has been the part that's just been the toughest to adapt to. So now the final question, am I happy with my decision to leave a full-time pay and schedule as a port certified internal medicine hospitalist where I was working every other week compared to now as a cardiology fellow where I'm making significantly less because I'm back in training, I'm working more hours, and life is definitely more hectic. And the answer is 100% yes, for a few reasons. For one, the company that I left where I was working as a hospitalist has since had a lot of turnover at their old job, so I already can start to feel like I made the right decision because other people have left for other reasons. Number two is I am actually enjoying coming to work. Being a fellow is not necessarily easy, but I feel like I can actually come and enjoy taking care of the patients that I'm taking care of because all the information and all the things I'm taking care of are in the field of cardiology. I'm not having to take care of inhalers or cirrhosis. Those are diseases that are important, but don't necessarily interest me. And so now I'm managing just the heart and cardiovascular diseases, which again I love. Number three, I feel like there's actually an end goal. Every time I come to work and I'm looking at an echo and I'm seeing a patient, I'm actually asking how can I store this information, the learning pearls to be a better cardiologist three, five, 10 years from now when I'm seeing patients in clinics. So fellowship really feels like a practical version to help me become a better attending three years down the line. Compared to when I was an internal medicine hospitalist, that was not the point at all. I was showing up for shifts. I was taking care of patients. I was trying to be as efficient as possible because we were really busy, but I wasn't always entirely focused and this is me being brutally honest of being a better doctor. I was just trying to get to the next patient, the next note, because we were again always busy. As a fellow, I have the opportunity of saying me taking care of these patients better, me understanding how to evaluate this echo, this cath lab image better will all help me better take care of these patients. Number four, I'm just four months in. So I'm really starting to just get the hang of what I need to know, but still know there's tons of gaps, but I know in a year from now and six months from now that information that knowledge is going to be so much more refined. I'll be able to walk in not just as a newbie, but somebody who actually knows how to make these decisions based off of data, based off of research, based off the pearls and my attendings and my patients have taught me. So just being able to see where I'm going to be able to transform to just from a year from now. And again, compared to my life as a hospice, I likely would have been a very similar clinician two to three years after my first year as being a hospice. That's not the case when I start my fellowship. And finally, although my schedule and my salary are nowhere as nice as what it used to be as a hospice and my life can definitely be busy again with a busy four-month old at home, I think ultimately I could see myself doing this career 20 plus years. That was not the same as me working as an internal medicine hospice, nothing against the field in itself. I've always seen made episodes of how much I actually enjoyed the job and I found something that I enjoyed better and I'm happy I made that move. I'm happy I made that leap. So if you guys have enjoyed this episode and you have more questions about my life as a fellow, my life as a cardiologist, go ahead and add them in the comment section down below if you're watching on YouTube. If you did enjoy this episode, if you enjoyed the breakdown, go ahead and hit that like button, that subscribe button definitely supports the channel. The listing is a podcast, go ahead and hit that follow and subscribe on your favorite listening platform. If you did enjoy this episode, check out this episode right here as my life as a full-time cardiology fellow as well as this episode right here on my morning routine as a cardiology fellow. Hopefully you guys enjoyed these. As always, my friends, thank you so much for joining me on my journey. Hopefully I was a little helped to you guys on yours. I'll see you guys in the next one. Peace.


Hello, and welcome to Noon Conference hosted by MRI Online. Noon Conference connects the global radiology community through free, live educational webinars that are accessible for all, and is an opportunity to learn alongside top radiologists from around the world. We encourage you to ask questions and share ideas to help the community learn and grow. Today, we are honored to welcome Dr. Inez Mohamed for a lecture entitled Psychological Safety as an AC-GME Requirement, Challenges and Solutions. Dr. Mohamed completed her residency at the University of Toledo and was an abdominal imaging fellow at the University Hospitals of Cleveland. She's an assistant professor of radiology, division of abdominal imaging at Case Western Reserve University, University Hospitals of Cleveland. She's also the associate program director of the radiology residency. At the end of the lecture, please join Dr. Mohamed in a live Q&A session, which he will address questions you may have on today's topic. Please remember to use the Q&A feature to submit your questions so we can get to as many as we can before our time is up. With that, we're ready to begin today's lecture. Dr. Mohamed, please take it from here. Hi, everyone. My name is Inez Mohamed. I am assistant professor of radiology, abdominal imaging and the associate program director of the residency. Today, we're going to talk about psychological safety as a new AC-GME requirement. I have nothing to disclose. Our objective today is to know what is psychological safety, what are the barriers, discuss the impact of creating a safety culture in healthcare and also to identify methods of fostering psychological safety in the residency program. So what is psychological safety? Psychological safety is a personal belief that one can speak up, take interpersonal risks, express concerns, admit mistakes without the fear of being shamed, blamed or ignored. The aim is to create a culture where everyone feels comfortable admitting their mistakes so that we can learn from our mistakes. We turn our failure into learning opportunities. So next time when we are faced with the same challenge, we are able to take better decisions. As of July 1, 2023, AC-GME has promoted psychological safety to be a requirement all residency programs have to comply. With the AC-GME common program requirement definition, psychological safety is an environment of trust and respect that allows individuals to feel able to ask for help, admit mistakes, raise concerns, suggest ideas and challenge ways of working and the ideas of others on the team, including those in authority without fear of humiliation and the knowledge that mistakes will be handed justly and thoroughly. Now that we know what psychological safety is, we have to stress what psychological safety is not. It's not eliminating personal accountability. It is not a permission to incompetence. It is not a guaranteed applause. If I am saying that I'm going to actively listen to you, that doesn't mean that I have to certainly agree. So psychological safety and accountability should go hand in hand in our residency programs. We don't want high psychological safety without accountability that will place our students in comfort zone. That means complacency. They don't have to do anything. If, of course, we don't want high accountability and low psychological safety, that's an anxiety zone. What we want is place our residents, our medical students in the learning zone where there are high accountability and high psychological safety. It is particularly challenging to foster psychological safety in healthcare. Why? There is built in hierarchy in medicine. We have medical students, junior residents, senior residents, junior attendings, senior attendings, section chiefs and so on. We also have different teams working together. We have nurses, we have admin, we have technicians and among these there is hierarchy. Hierarchy is not built in to be a bad thing. Actually, the most senior person is more knowledgeable and this is put in place as checks and balances to ensure patient safety, to have better patient outcome. The problem, of course, is that it makes picking up or building a safe culture more difficult. Other thing, of course, is lack of awareness. Why do we have to implement psychological safety? Multi-generational workforce. Most of our residents are in the new millennials. Last year, Radiology actually matched the first generation Z. Each generation have their own aspiration, their own way of communication, their own ways that they want to learn through. Other thing, of course, is that in medicine in general, it's challenging and fast-paced environments. Sometimes we have to take a crucial decision within seconds to save patients' lives. It's not really easier in Radiology. A big factor, a pillar for psychological safety is having interpersonal relationship between the education and learner. Radiology now is a hybrid learning environment where people are working remotely. Also, sometimes residents are working with attendings face-to-face in the reading room in the morning and then they go on call and they are dealing with attendings. They have never seen before. Other thing is that we are all under stress from the increasing clinical volume coupled with Radiology's shortage. So why does it matter? Why is it important to actually have psychological safety in our programs? Chernobyl, April 26, 1986. The worst nuclear disaster in history. Hundreds were killed, thousands left with consequences of high radiation exposure, including cancer. The Committee for Safety in Nuclear Installation in their report on this incident for the first time they introduced the term safety culture. It was said that that day in the control room, there were workers who knew that something was wrong with the experiment that they were doing. But they were so afraid, they were so worried that they would be humiliated. They were so afraid that if they spoke up to those in power, they might get fired. Also, it was said that there were two explosions that day. The people who actually managed to escape the first explosion were so occupied with who is going to be blamed for this disaster that they did not tell the people who were living within the vicinity of this nuclear implant of this disaster that they have to run for their lives. The people did not evacuate in this city for 36 hours. Fast forward 2003. Amy Edmondson was a PhD student. She was going from one hospital ward to the other in a pediatric hospital. She was studying the relationship between working in a healthy environment, high trust environment, and mistakes. That's when she found out something that did not make sense to her. She found out something that was controversial. She found out that nurses who work in effective teams who have good relationship, who have good leaders were actually doing more mistakes than nurses who are working in a few culture. When she investigated that further, she found out that, no, they did not do more mistakes. They actually reported more mistakes. And that's when she wrote her 2004 paper Learning from Failure in Healthcare. Dr. Amy Edmondson is the first to introduce the term psychological safety. She is a godmother of psychological safety. If you Google psychological safety right now, you will see her pictures, her talk. You will also see lots of information about the importance of psychological safety in business, in economy, but in fact psychological safety was implemented for medicine. Why? Study after study has proven that there is a direct correlation between patient outcome and healthcare team working in a safety culture. I want you to grab your attention to this particular paper, which I think was very alarming. This paper was published in Annals of Surgery in 2019. Imagine a complex abdominal surgery going on. And there was in the OR, there was a resident, the surgeon who I am quoting here was notorious for explosive triads and flying objects. And there was this invisible medical student who was watching the surgery going from far away. And when he noticed that, the green towel that's supposed to cover the handle where they moved the light was missing. And he also saw the surgeon and the medical student repeatedly reaching out and touching this handle, which means that the surgery was contaminated, but he chose willingly not to speak up. And he was scared that he's going to be humiliated from that surgeon, that he maybe he's not going to get the residency of the surgery residency that he wants. By doing so, by not speaking up, he puts the patient under a severe risk of infection and sepsis. The important thing that we have to be aware of is that we work in an environment of shared knowledge, not one person knows everything. Everyone in the team have bits and pieces of information. And sometimes the most important information is not with the chair, it's not with the vice chair, it's not with the section head, not even the attending. The important piece of information that's going to affect the patient is going to be with our frontline workers, which is sometimes a medical student, the technician, the nurse, the resident. That's why if we want to protect the patient, we have to protect the well-being of those entitled to care for them. Of course, there is a big correlation between burnout, which is emotional exhaustion, depersonalization and low personal accomplishment among residents in healthcare. This particular paper, which was published in Medical Science Education in 2020, had this survey of 110 residents in University of California from various programs, some from pathology, some from pediatrics, some from radiology, some from surgery. And they give them this questionnaire about mistreatment, mistreatment anywhere from gender and racial discrimination to belittlement and humiliation. And they give them the mass slash burnout inventory, which is a standardized survey for prevalence of burnout. What they found out was that 42% of the residents witnessed mistreatment of the co-residents, 25% reported personal mistreatment. Those who reported personal mistreatment were eight times more likely to have burnout and four times more likely to report an anxiety and depression. They found no significant relationship between depression, burnout and anxiety, and the specialty, it doesn't matter if they were in surgery or in pathology. It didn't matter if they had student debt, it didn't matter the race and the gender. The most important finding, in my opinion, was that mistreatment is rarely reported to institutions due to fear of retaliation or believe that they will be ignored. So if a resident or a medical student approach you and tell you something is wrong, most likely this is just the tip of the iceberg. There is more going on and that's why we have to actively dig for psychological safety breaches. We have residents, we have medical students because we want to teach them, right? So one of the very important implications of psychological safety is on the learning ability. We have to understand the court of the people we are dealing with. For a medical student, for a resident to get where they are today, they have continuously proven their success. They might be perfectionist or overachievers. These cohorts are particularly susceptible for what we call imposter syndrome. What is imposter syndrome? It's chronic feelings of self-doubt and fear of being discovered as an intellectual fraud. Imposter syndrome makes them more sensitive to criticism and more aspiring, striving on being acknowledged and being validated. In early 1900s two pathologists called Yerks and Dotson had this experiment. They had mice and they gave this group of mice a small amount of electric shock. What they found was that this small amount of electric shock actually increased their learning ability and improved their performance. They were better able to actually perform the tasks that they wanted them to do. When they actually increased the intensity of the electric shock beyond a certain limit, the mice focused on the pain. Their learning ability markedly declined and they were not able to perform the task. That's when the Yerks-Dotson curve came out, which is actually the relationship between the performance efficiency and anxiety. An optimal level of stress like having an exam, taking an exam can help you focus on the task. Too much anxiety can impair your ability to concentrate and your performance begins to degrade. We see that in our residency programs when we're part of CC meetings, when we see a sudden dip in the performance of residents who were before that doing well. I personally call that the cycle of fear.  Now they have this self-doubt. They go into an anxiety. Next time they're on call, they lose focus, more mistakes, and so on and so forth. The most important question, what can we do better in our programs? This is in a nutshell what we can do better at an institutional level, interpersonal level, and individual level. These are not islands. These are actually complementary, intercommunicated. In my opinion, institutional is the easiest to implement. Interpersonal is a little bit more difficult. The most difficult by far is the ones that are individual or personal level. The supporting mental health, financial assistance, childcare support, struggling residents, whether academically or professionally. I think each topic in these needs are one hour by itself. Today I'm going to, within maybe the next 20 minutes or 30 minutes, I'm going to focus on the institutional and the interpersonal level. I believe the most important is feedback. First, I'm going to start with, how can we train our residents to better receive negative feedback? When someone approaches me with a negative feedback, when someone approaches me and tells me, you're not doing this right, you have to fix it. The first thing that has to come to my mind is gratitude. The person actually takes the time, who cares enough, who takes the interpersonal risk. Like they are risking the relationship with me to tell me, I am doing something wrong and how to fix it. This person is a good guy. This is the person who cares about me. Second, we must have a growth mindset. A fixed mindset is that I made a mistake. I'm a failure. I give up. The growth mindset is I made a mistake. This is a learning opportunity. Next time I'm going to work on myself and I'm not going to repeat this mistake again. As Maya Angelou said, do the best you can until you know better than when you know better, do better. Emotional intelligence, they would tell you, when you face a flare of emotions, wait and identify your emotion. Name your emotion. You can navigate the feelings through this emotional wheel. Are you actually mad or embarrassed? Are you threatened or guilty? Are you overwhelmed or frustrated? Name your feeling. What are you feeling right now? And then forgive yourself. If somebody told you, I've never made a mistake in my life, they're not saying the truth. Everybody makes mistakes. We fail fast to succeed sooner. And then once we take all our time to actually absorb our feelings, know what's going on, and we must come make a plan. Make a plan before it's too late. If somebody told you on your first call that this was not the right thing to do, make a plan to fix it. Then, second thing is how can we deliver a negative feedback? We can use the six W's of investigation or we can say six W's of negative feedback. Before you give someone a negative feedback, ask yourself these six questions. Why am I giving this person the negative feedback to make them feel bad about themselves or to actually teach them something so that next time they would not repeat the mistake? Where am I giving the feedback? Is it in a safe place for both of us? Is it in my office? Is it where no one can hear? Or is it in a conference room? Or is it where in public or everybody can hear what I'm saying? Who am I giving the feedback to? What is my relationship with this person? And more importantly, what do I want this relationship with this person to be at the end of this conversation? At the end of the day, we are all colleagues, right? What are we saying? Are we saying how dare you? What year are you? How come an R3 doesn't know that? Or am I telling them, come, let's look at this case again. Tell me what you think about it. How are we giving the feedback is very important, because if I'm looking to somebody face to face, you know, I'm looking at their expression. Are they mad? Are they smiling? But if I'm sending, like, let's say a PAX chat or an email, there is a very big chance of misunderstanding. And when? When am I giving the feedback? Is it at 10 a.m. in the morning? Is it at a lunch break or at 2 a.m. when the whole world is collapsing? When they can't keep up, they can't open their eyes and they can't keep up with the list. The key elements of what we are going to say for an effective feedback is that it has to be specific, not vague or general, not limited to items per feedback. It has to be objective, of course, not judgmental or personal. It has to be constructive based on clear expectation. It has to be fair and honest. And most importantly, it has to be actionable, meaning that I told you you missed this finding in the Yota. Here is a paper or an article or a book about Yota with that. And by far, the most important thing when we as educators give a negative feedback to a learner, whether it's a medical student or a resident is empathy. What is empathy? The ability to understand and share the feelings, thoughts and experience of another person from their perspective. Put yourself in your learner's shoes. Demolizing the learner is going to have the opposite effect. This is a paper in the annals of New Zealand in surgery and they were talking about something very important. They were saying that the residents who are most in need of support, compassion and guidance and encouragement are actually the struggling residents. And if we have residents who is on probation or performance alert or they're not doing well, if we put them on do more pressure, it's going to have a totally different outcome. And another important thing that they talked about and quite frankly, some of us are actually guilty of it or maybe all is an observer bias. When I open a report from a resident on call, and I know that this person is atop of their class, they are doing very well, and I open the report and they're missing something in the back of my mind. Oh, most likely they had a bad night. Most likely there was lots of interruptions. This is not at all what's going to be if that same mistake was done by a resident who I know they're not doing well. So we have to avoid observer bias in judging performance of struggling residents. We can't stress enough on the importance of positive feedback. If you see something good, say something good. We, quite frankly, we do very well with focusing on negative feedback. When somebody is doing something wrong, we'll go to them and tell them, oh, fix this, but we're not doing a very good job when someone is doing something good, we tell them that they are doing something good. And as we said before, the cohort of the residents and the medical students we're dealing with are these overachievers and perfectionist. Positive feedback can boost the confidence and help combat imposter syndrome. Switching gears now to clear goals and educational strategies. These are four suggestions for strategies that we can give our medical students clear expectations and goals. First, preset expectations. If we can tell the residents before every rotation, these are the goals and objectives based on your level of training based on ACG and E guidelines that you're supposed to have. These are the milestones. These are the numbers of study that you are supposed to read based on your level of training. This is your responsibility. This is your working hour. You know, they, let's say they're supposed to work from 8 to 5, but if they have a moding conference, they are expected to be there at 9am. Other thing which we can help our residents with is structured learning agenda. We said that most of our residents are young millennials and Generation Z. These generations are tech savvy. They are used to getting information quickly through online.  If we can give our residents, let's say a four week structured curriculum with exactly what they're supposed to read per week, that's of course going to be very helpful. Other thing which some papers actually have found helpful and we have did the survey in our program is Meditation Evaluation. Giving formal or informal mid rotation feedback to the residents can help them actually know where they are, and if they are not doing well, they will have enough time in the rotation to improve. Of course, formal competency evaluation is an ACG requirement. All ACGME accredited programs must be doing this. They must have a CCC meeting, a CCC committee, clinical competency committee, which is responsible for formal evaluation of the performance of the residents based on ACGME milestones. These are very, very, like if we are planning to give our residents this structured agenda, this is a very good guide for us. The top 10 reading lists from Radiographics, it's beautiful. We can actually divide it based on speciality or rotation and give you basic and intermediate level, what radicals, radiographic articles, which is kind of addressing trainings, trainees or residents. Another thing, of course, is the Radiology Resident Collection Series. Again, these are divided by body parts and there are lots of videos in there that you can actually let the residents look at these videos. Also, the AOR, the APDR, through their, the Association of Program Director of Radiologists, through their education committee, I think they are about to come out with something similar to that with a structured learning agenda for all residents based on level of training and the rotation they are going into. Another thing we want to talk about is the Pygmalion Effect. We said that we want to give our residents clear expectations before the rotation, what is the number of study I'm supposed to read. We don't want to give them, we don't want to give an R1 on the first CT rotation, 40 studies per day, we're setting them for failure. They might not be able to do that. And also we don't want to tell them read four studies per day. You know, this Pygmalion Effect or self-fulfilling prophecy is that in education it says that learners do better with more is expected of them. Then we go to the reword, go to our reading rooms, our conference. How can we foster psychological safety in the learning space? First, in the reading room, this was a big chunk of what I'm saying now was very beautifully outlined in a paper by Dr. Diet and Dr. Patrick Lewis and Dr. Gadde. It's in the Journal of American College of Radiology that was published in 2023. First thing we want to do as educators is encourage inquiry. The learner's question reflects a knowledge gap that will affect patient care. I want the resident to ask me now when we are together staffing out the case, tell me the question that they have, admit that they have the stuff that they don't know, you know, so that that will affect how the performance when they buy themselves on call. So how can we do that? We want to, as we teach our residents in the reading room, we want to give follow-up non-intimidating questions to make sure that they understand what we are saying and actually encourage them to ask questions. It's okay to say I don't know. Other than that is modeling intellectual humility. What is intellectual humility is my awareness that there is limit to my own knowledge and that each encounter is a chance to gain knowledge. How can I model intellectual humility by simply admitting that there is stuff that I don't know? Like if I am as a junior attending, there is a case that I don't really, I'm not sure what the diagnosis is. It's okay to model humility and go ask a senior attending or let's say I'm reading a CT of the abdomen and there's something the spine that I don't know. It's okay to ask a new radiologist, admitting my own limitation can build trust and motivate trainees to admit knowledge gaps. Lastly, we have to actively explore psychological safety breaches. If there is a resident that appears emotionally distressed or disengaged, we want to actively go and ask them, how are you doing? Second conference setting. Of course, the diagnostic oral exam are back. So ABR, this, like all ones right now, they're going to take the new ABR oral exam and that's why we will have to go back to the hot seat sessions. So how can we cool the hot seat session? The first suggestion is to use the volunteer method, meaning that I don't have to call one person out. I can say I want an R2 and R3 and someone volunteer. If they're struggling, we can allow them to call a friend. If they're struggling, you can ask one of your colleagues. And then emphasize on the thought process. It's okay if they didn't reach the diagnosis, just tell them that the thought process was right. They described the lesion well. Don't give them 10 million MRI sequences. Just tell them, give them a couple of images or a couple of sequences and tell them maybe focus on the liver. The alternative would be, of course, the anonymous audience response system like Poll Everywhere. Other challenge that we have as educators when preparing for either didactic or case conference is the generation gap. We have millennials. I mean, we don't want to brush everybody like paint everybody with the same brush, but it is acknowledged that young millennials in particular have short attention span. So you kind of have to actively grab their attention, especially in didactic lectures. Generation Z are the first generation who are totally immersed in technology. They have no awareness of life before the internet, right? They are digital natives. They have information at their fingertips. So maybe we can always, even if we're giving a didactic lecture, we can make it more interesting by putting questions before and after. And there is something called gamification. It's an active type of learning like simulation or using games to actually or group case activities. And I think there is a site like the school Kahoot that actually can help us with gamification of our cases. Another thing is flipped classroom. The traditional classroom is actually when we give a didactic lecture and then the student or the learner goes home and studies. The flipped classroom is other way around. It can advance like online articles or videos to watch. And then the lecture can be dedicated to more case discussion or asking them for them to ask questions. And of course, we have to incorporate online and table based learning resources. Mentorship. Mentorship is a relation between a mentor and a mentee. And its effect is actually, it affects the mentee, the mentor and the program or the institute as a whole. For the mentee, it contributes to the wellness, career, growth and jobs, its faction. For the mentor, it's a personal expression of thanks for the past and hope for the future. It can keep this senior faculty up to date and help avoid their burnout. For the program, when they foster an effective mentor mentee program, they will have be rewarded with greater clinical and academic productivity. They will have high rates of faculty retention and promotion. The quality of a good mentee is that they embrace constructive feedback, be cognizant of the mentor's time, follow through on assigned tax and maintain optimism. They should also, it's expected that they show gratitude, appreciation, professionalism and ethical behavior. A good mentor and effective mentor is the one that shows enthusiasm, genuine concern and empathy about the mentee and availability. How can our programs build an effective mentor group? First, they have to encourage faculty to be mentors, reward them for their time, offer them protected time, funding, CME credit, put mentorship, incorporate mentorship as a criteria for promotion. Second, they have to do matchmaking. You have to match a mentor with a mentee that they share common interests. Both of them have to commit to confidentiality. Whatever happens, whatever is said between the mentor and mentee should stay confidential. Of course, representation for like unrepresented minorities. I mean, it's not crucial to match a female mentee to a female mentor, actually. As we know, we have only 26% of the radiologists as females, maybe 13% of them are in leadership position. If we're going to limit our female residents to only female radiologists, we're kind of limiting their chances. So it is good to match like the same cohort, if you would say, but it's not essential and also you can have more than one mentor. Mentors as sponsors. Sponsors actually take mentorship to the next level. They can put their mentee in the spotlight. They can support the application for a national committee. They can write strong letter of recommendation. They can personally use their power in their radiological society to nominate the mentees for talks at a regional or national level. Mentoring up is actually a concept. That actually is taken from the economic concept of managing up, meaning that the burden of the mentorship does not fall only on the mentor. The mentee has to share the responsibility. Mentoring up is basically a mentee-driven mentoring relationship. The mentee has to take the initiative to tell the mentor what are their goals and objectives from this mentorship relationship. What are the gaps in their knowledge and skills and set objective and attainable objectives and expectations. Lastly, online resources. We don't have to limit our residents or ourselves actually to just having mentors reason our institutes. There are plethora of online resources. In this paper actually there was by our prior residents, Elias Kikano and our current abdominal imaging attending Dr. Ramaya. They actually lay there beautifully all the resources that you can have if you need an online mentor. If you want to be a mentor or a mentee, you can go to one of these. There is the AOR, the RSNA, the SAR, if you want to sub-specialties like site of abdominal radiology and so on. As we said, big part of building a safe culture is having a good interpersonal relationship. How can we improve the interactions of our, like all the team. It doesn't have to be just resident radiologists, maybe technicians and nurses and admins. We can plan social activities together. This can be departmental or small groups. It can be an ice breaker, a low stress ice breaker where technologists and radiologists and residents meet together. Also, we can do meet and greet for new attendings. And in this meet and greet, we can put like videos for like staff communication, how to use nonverbal communications. And another important thing which is kind of, we as educators, we as radiologists as attendings, we want to know how well are we doing as far as communication. If we can provide as a program, anonymous, routine anonymous feedback to the radiologists, how well are they doing as far as communication with the residents and put it in a graph. Like if you get, if I get the feedback and I'm getting eight out of 10, is eight out of 10 a good thing? Or is most of the faculty is nine and nine out of 10? Or am I much better than everybody else? So that will actually help me know where I stand as far as psychological safety. We have to assess psychological safety. We have to actively assess psychological safety. And the first thing we have to know when we are assessing psychological safety, when we're asking the residents is something going wrong is that it has to be a bidirectional communication. Silence is a communication. You know, if somebody came and told me this is going wrong to me, to somebody else, this is a bad behavior, something abusive, abusive is happening. I must close the loop and go and tell that person, this is what we are trying to do. This is what we did. This is how we try to fix this problem. In the definition of psychological safety is that that person when they speak up, they're not going to be ignored. How can we assess psychological safety? We can, of course, we have to provide our residents or medical students a tool for anonymous feedback that they can send the feedback if they don't want to be known or identified. They can have this tool to actually give an anonymous feedback or a safety report without being identified. The other thing is that the fact that I never said that I don't want anybody not to approach me and tell me of something going on, that's not really how it has to be perceived. I have to actually actively tell them that I want to, I'm listening to you. I want to know if something is going wrong. Leadership Walkarounds is actually an institutional initiatives where leaders actively engage with frontline workers in various clinical settings to identify safety risks. They have to focus on accomplishment, recognition and reinforcement to build trust. Last psychological safety surveys. Residency programs have to send regular standardized anonymous surveys to assess safety, teamwork, work-life balance, burnout and depression. And there are several standardized surveys that can assess the psychological safety score survey or the mass slash burnout inventory. This was actually an example of a psychological safety survey that was published in the Journal of Patient Safety in 2022. It has this question that, through which we can use to assess psychological safety, is it difficult to speak up if I have a problem? Is it easy to ask questions when there is something that we don't understand? Are disagreements appropriately resolved? Does the culture make it easy to learn from errors? Is it difficult to discuss or speak up about errors? Are my suggestions taken seriously? Last but not least, radiologists as educators. We are human beings too. We are under stress, you know. I believe the biggest transition in our career is not really the first day in medical school. It's not really the first day in residency or fellowship. It is that day you transition from being a fellow to being an attending. This first day that you are actually there, you are signing the report, you are responsible for the list. And then on top of that, I have a first-year resident that I have to teach. We are not teaching our residents to be educators. We are teaching them to be radiologists, right? They know how to read, but they don't know how to educate. So, radiology programs, residency programs have to adopt a culture where it is important to, as part of their required scholarly activities, is education. We have to train, practice, provide feedback to our residents about being educators. We have to give them protected time to go and educate the junior residents and the medical students. Other than that, we have to optimize educational interactions. It is, I think, it has been mentioned before, I think at AOR meetings that some residency programs give a different list, assign a different reading list to attendings who are working with residents. It can be a lower volume working list so that they have more time, they have more time to actually teach the residents, give them protected time to prepare for lectures. As much as possible, decrease interruptions, phone calls, or anything that would affect efficiency. Career advancement, I mean, there is a most, I mean, every institute is different as far as their promotion, but I mean, I believe most of the time it's difficult to be promoted as an educator. In fact, Dr. Petra Lewis have in this known conference, she has a very, very, very, an excellent actually lecture talk about how to be promoted as an educator. I personally watched that twice. It is important to give us clear guide to how to be promoted as educators. You know, it's not just just about number of publications. I want to be my education activity to be taken into account. This will encourage more faculty to spend more time and effort educating residents. This will also encourage more faculty development, okay. We have to increase the awareness of importance of psychological safety. As we said before, give them individualized feedback. If we feel that they're not doing very well in their interpersonal communication, we can give them, provide them with training if needed be. At the end, I will leave you with this quote from Maya Angelou, people will forget what you said, people will forget what you did, but they will never forget what you made them feel. This is actually the paper, if you want to know more about psychological safety. This was a paper we recently published in academic ideology. It has much more details than what we just said in this talk. And thank you. Thank you so much, Dr. Mohammed for sharing your lecture today at this time will open the floor up for some questions. If folks want to ask a question you can put it into the Q&A feature. Sometimes it takes a couple of seconds. Questions to come in. Dr. Mohammed I'm curious what kinds of things in your own program have you been implementing in service of psychological safety and what's worked so far. I think building this anonymous surveys and giving them, we actually receive lots of these anonymous surveys that actually initiated by the residents. We also have these town halls, like it's just the education team and the residents together. We have formal and informal mentorship groups like we have, we kind of match, make our resident with an attending. And the way we do it is that if a resident tells me I'm interested in abdominal imaging they're going to go with an abdominal imaging attending but it doesn't have to be just this attending. They can freely actually pick any mentor that they want from the faculty. There's a lot of talk about burnout and across radiologists in any part of their career and wondering is there any advice on how medical students or residents can ask for accommodations or what this looks like in an environment where psychological safety is paramount and foremost. So burnout actually we have to give our first of all they have we have to give them the space to actually talk about it. You know, there is two ways, either we actually approach the resident who appear that they are disengaged or appear that they are depressed and actively asking them if there is something going on. Because burnout have so many, burnout have so many reasons you know it can it doesn't have to be just the workload right it doesn't have to be sometimes there's something going on in their personal life like a resident just had a new baby or somebody just got married or they need some time off you know something is going on in their life. So the first thing is actually actively listening. If somebody appears to be depressed or disengaged, we want to actually reach to them and ask them and try to try to listen to them and know what's what's going on. I think that's it for the questions. So I think we'll wrap there, Dr. Muhammad thank you again for this lecture and everyone else for being here and participating in this new conference we really appreciate it. You can access the recording of today's conference and all our previous new conferences by creating a free MRI online account. And be sure to join us again this week, Thursday, October 19 at 12pm Eastern, featuring Dr Stephen row for a lecture entitled current radio pharmaceutical serenastic applications and nuclear medicine. You can register for this free lecture at mr online calm, follow us on social media for updates on future new conferences. Thanks again Dr Muhammad and everyone else have a great day.


So I have long maintained that whatever we see bipartisan support for a particular piece of legislation and Congress that usually means that we should be worried because both Democrats and Republicans are teaming up to probably screw over the American people and I'm skeptical because whenever we actually see both parties agree on something usually they are expanding our already bloated military budget or agreeing on more Austerity so it's usually bad But in this instance we see a bill with Bipartisan support so universal that the Senate passed it unanimously. So you've got to think how bad is it, right? It's actually Not bad. In fact, most people would agree that it's good. It's popular and there are some benefits with regard to mental health Shocking right not even a single holdout. Well, what is it? Well, it's the Sunshine Protection Act and as Alexander Bolton of the Hill explains the Senate on Tuesday approved a proposal To make daylight saving time permanent Which if passed in the house and signed by President Biden would mean Americans would never again have to set their clocks back an hour and Lose an hour of afternoon daylight in the fall and winter if enacted into law It would also mean that early risers lose an hour of daylight in the mornings in November December January and February Now what's shocking to me is that there wasn't a single holdout even Mitch McConnell supported this You'd think that he'd be opposed to this just to suck more life out of the American people just to be mean But he supports this too Now immediately after this past it started to trend on Twitter because people were shocked that something like this That's popular would get passed because our Congress is functionally incapable of doing anything So the fact that they did this with universal support It's honestly weird to see now a poll conducted by the Economist and you go found that two-thirds of Americans Prefer to not have to change the clocks twice a year and Specifically they want the extra hour of daylight in the evenings or permanent spring forward mode now aside from the fact That this is incredibly popular There's also a lot of health benefits as I alluded to at the beginning of this video now This is all laid out in an article for CNN Co-written by Ed Markey and Marco Rubio. Yes that Ed Markey and that Marco Rubio. This is Weird it feels wrong almost but here's what they say the effects of darker afternoons on our mental and physical health can Be serious the bi-annual transition of spring forward and fall back Disrupts circadian sleeping patterns causing confusion sleep disturbances and even an elevated risk to heart health the rate of heart attacks spikes by 24% in the days following spring forward in March according to a 2014 study from the University of Michigan Another study published in 2016 found stroke rates may also increase by 8% Year-round daylight saving time could also decrease the likelihood of fatal car accidents Which jumped 6% in the days following the time change according to a 2020 study from the University of Colorado a Stolen evening sunlight can also negatively impact mental health a Danish study found that hospitals seen 11% uptick in patients With symptoms of depression immediately following the switch from sunnier daylight saving time to the darker standard time in the fall By making our days brighter year-round we can also permanently speed up the clock on seasonal depression Triggered by the dark days of winter. Okay, so it sounds good I actually did not know all of this, but it seems reasonable I For one do experience seasonal depression typically around the time where we have to set the clocks back and it gets darker earlier Um, it just it feels really dreadful and I hate it So this all makes sense to me now for all of the benefits I have to point out that there are Potential drawbacks so a lot of people don't know this but actually in the 1970s we did this before 79% of the American people wanted permanent daylight savings time, but guess what after they did it support for that dropped by 37 points why well because pre sunrise Fatalities actually increased by 2% Particularly for school aged children who were hit by cars and it was just more dangerous for them to go to school Well, it was still dark and this actually prompted some schools to delay start times until the sun came up just because they thought that It was so dangerous now if you want to read the full story about this I'll link you to a Washingtonian article, which is really interesting and I don't think a lot of people actually know about this So we've been here before where everybody wanted permanent daylight savings times They did it and then everybody said no no change it back. We don't like it. Um, so will this happen again? Who knows but I mean it's kind of a balance, right? There are drawbacks to having to set the time back Spring forward fall back I mean the seasonal depression and whatnot, but there's also some potential downsides to this as well So it's important to keep that in mind. I for one You know, I I think I support this overall Hopefully the situation wouldn't be as disastrous as it was the first time when we changed this back But let's go to the internet to get some reactions because this was trending. So looking at the trending page I think that the responses here were pretty humorous Mark Burns asks rhetorically, but who will enforce the Sunshine Protection Act? Well, of course Mario who else? Karen says I don't need the Sunshine Protection Act because I already have all the sunlight I need now She shares a picture of one of the stars from k-pop sensation monster X Lindsay says everyone is so excited for the Sunshine Protection Act me meanwhile I like darkness so I would prefer that this past but um, you know, we'll see It's just some positive news and to actually unironically applaud Republicans and Democrats in the Senate's in the Senate of all places it feels wrong. It feels like I should feel bad and shame In shame because I'm saying that they did good, but unironically they did something good and that's Again, it just feels I feel dirty saying it. So um Yeah, take from this what you will we may not have to set the clocks ahead or back ever again


All right separatrators welcome on back here this Monday August 21st Shortly after 2 30 p.m. Eastern time. We have to be quick with our words here Welcome on back for this afternoon meeting, but we have class on ahead here We have the phase one stock course continuing on this afternoon So I know that we just posted the link to that inside our main chat board So you know hey for all of our students and members alike here. Just give me a quick sound check Let me know if you can hear me loud and clear Perhaps clear, but throw it a little horse little under the weather right now today And feel a little bit better, but still probably some hot tea little honey in there all good stuff So great to see the later Rick Barbara Larry Sam Donald's all out and clear from them. Perfect. There we go Tutobeme says Andrea. There we go. Perfect. So that in mind Let's hop right to it here. I own queue up nearly like up over 6% now at the stage So no, it's at the highs That's the part that we want to focus on here during this exact time of the day for a stock going into this Afternoon meeting for it to be near the highs at the highs or inversely at the lows, you know That could be nice to see so the market's been making a nice little recovery across the early afternoon To what extent are we gonna see this continue though? And you know, obviously tays only Monday So we had a lot of time to determine that I don't think that we're gonna see too much continuation at first I think that we do pull back a little more in terms of like, you know mid to long term I definitely think that we're gonna make a solid run going into September or October like a really strong melt-up perhaps in the market I'll dig more into that perhaps tomorrow in our traders talk workshop But here we go right now I own queue definitely gonna just put this on our watch list to begin and hopefully a bunch of other stocks That look like I own queue here. Let's go from top to bottom though. I'm gonna skip over skip over TMBR It's a buyout right there. We move forward You know, it was interesting on the news of that trade early this morning So it wasn't really moving like a buyout at first, but it flattened out and we knew pretty early on from that point All right, stay away from it. Oh, BIO Biotech company I'd imagine at the highs but very thin on the books. So I'm gonna pass there actually for right now TSAT this doc has had a little bit more activity that we've seen over the last week So we're you know kind of more familiar with this trade back from Tuesday and Wednesday of last week popped up pretty nice You know broke over those highs actually here So, you know looking even stronger now perhaps it is pretty thin on the book I'd actually say it's like as liquid as the other stock which is even cheaper than this So if I'm compared apples to oranges, I don't mind this TSAT over that. What was it the OB IO? So, you know, at least I'll put this one on our watch list for right now chart looks good here. Is it day trade? All right, we keep it going here. Let's see what else we can grab BGLC Closer to its highs and it's lows. So, you know, maybe I'll come back to this if I need to let's see if there's anything even sharper on the way up It's not a sharp of late this alvr A sharp in the morning fell pretty dull just recently here flattened out after 12 o'clock You know a nice little move up towards the highs, but not as familiar with that trade Again, we'll kind of label a day like today Monday on in August It's like the dog days of summer So now you want to kind of just be very picky and choose you with what we're putting on our watch lists You know, we would say that on any given day, right? I mean we're risking our hard-earned money as I like to phrase it as well So I'm not just gonna jump into anything. I know that most of us know that here, but even furthermore Today on a day like today So that brings you back to AOI AOI had a nice pop at the market open Fausto had called that one out early on and made a great run up towards just about 1550 Right now as you could see it's trying to eat back up again So, you know, we're more familiar with the stock like we kind of said with the IO and Q and yeah I don't mind putting this one on our list for right now to the AOI All right, what else we got here. So nvax make a big shake earlier. I guess that was like a noon time here I haven't really looked at it since personally and perhaps rich had it up inside our trading room afterwards but I stepped away and then wow really nice recovery broke highs here and You know, this is still near the high of the day off of 850, right? So is it possible for this to hold and then run up even further? it is You know for right now, I guess I'll be friendly and put this on our watch list makes the cut as I would say for right now All right, so let's see what else we can get here though on the gainer side markets are up So we'll see what's on the loser is just in a moment, but oh Here's a good one s Like good. We'll see if it continues, but nice pop heading into the mid-afternoon just kind of out of nowhere So news related pop the stock got halted off of I think volatility if anything But the headline that came out was Sentinel one has hired investment bank Analyst partners to advise on discussions with potential Acquires so I guess they're trying to do a sale by the rumor sell the news So led to a nice little pop earlier and just before you know It pulled back and the easy to say part is well it bounced and it ended up bouncing from where it essentially got halted from at 1627 and since it's made a 50 cent move so I really like this trade as of now It's moved back up pretty nicely. It's not necessarily at the high of the day, mind you But great liquidity and the good trends volatile off the news that came out. We'll take it Alright, so let me know if there's anything else looking good here folks I'm just doing one last look skimming down the gainer side here There's definitely a lot more that's up that like five plus percent that I ask out of you. So Do a really quick rummage through here. I mean stock like Tesla perhaps moving with the market and at the highs TSLL is the ETF that tracks the equity actually There's not as many of these single stock ETFs out there But no, we were following this that we were following this ETF early in the pre-market It's funny that I just said in class earlier today. Hey as a new student of CTU stay away from trading ETF Well, hey, I'll die on that hill that I'll stand by that a hundred out of a hundred times to newly enrolled students But there's a reason I put this on the pre-market watch list earlier at like, you know 745 It's because if Tesla were to move and if you're a more experienced trader here inside our room There's a lot of us quick little shout out to 2 I see in particular There's a lot of us but quick shout out to Andrean and Grant So, you know, if you know what to follow in Tesla and how to plan out your levels there And certainly if you have level 4 if you have book map, you know, it makes a lot easier to follow this TSLL It's an ETF mind you So if you don't have book map that I would not suggest for you to be trading it But otherwise like if you do follow Tesla pretty well and you could chart levels nicely for Tesla Then this is likely to make a pretty synonymous move. All right So I'm telling you got a lot of good students in our room here a lot of good traders I can go down the whole list probably more people in for tomorrow morning, but See what we can grab here.  What a downtrend. I had no idea this was looking as good No idea. I mean if rich was calling it out once again I've been in and out of my desk over the last like hour.  Wow, what a drop-off this thing is making right now Easy to say but phenomenal short throughout the whole day Let's take a look here just to see No, so we're not really too close to all-time lows army. I mean, that's all right. Just checking. I was just curious So, you know if anything it's got a ways to go to get to like the next major historical and bottom at least that is right Around 15 or 16 or so. So you'd really hope to see 20 hold long term if you're looking for a bounce on this NSSC trade You know what? Let me just double check the news. I got a little time here not too much But we got class ahead and I've been pretty efficient so far. So let's just jump to Benzinga here I'm sure that we had posted earlier in the chat board, but this is simple So NSSC trading lower after the company reported preliminary Q4 results Multiple firms lower the ratings and respective price targets. That's it. He's this thing's getting clobbered down over 47% right now So, you know, we'll see what happens I certainly look to respect the trend first and foremost and then if it begins to build higher lows or break a local trend line on The way down that's different. But yeah, let's follow this as a short here still All right, so let's see what else we got here though I mean not everything is moving up with the market AMC down over 23% right now It took a huge hit heading into the morning here. Oh My god, what a short this thing ended up dropping off early on and It was hard to borrow from you on trade stations. So it's hard to borrow for you It's running on thin shares across the board I'd say but you can fly puts on it first and then otherwise if it is easy to borrow then look at this trap I mean goes to show that there could have been plenty of opportunity on the way down here for the stock I don't know if there was any special news that came out overnight or into this morning That led to this right at the market open, but this thing got killed If that's the case, I wonder if like the eight AMC dividend. Nope didn't move up at all It's actually funny. Those two tickers trade inversely oftentimes All right, let's see what else we can grab though here real. I mean, this is getting a little closer to the ground floor HL heckler mining from earlier a little slower there not really too interested in a slower short You want something liquid but not something that's like yeah watching like the paint dry This is kind of in the gray area between that right because this is liquid This is steady on the way down easy to borrow under armor It is a little slow though, right? So you just said that before on the other one by you a a and you those are at least a little Little higher price, I guess so I don't mind slipping one of them on as a short possibility If you're looking for more like a level one level two type of short That would be it wouldn't want to really get any slower than that because it's just not worth the time then All right, so Chuck saying CBNA pushing we'll take a look at that here quick Yeah, it's you know, not up a whole lot percentage wise There's definitely gonna be some good stocks that look like that maybe even better I know one of us is calling out AI just earlier this morning and it was a really choppy trade as you could see throughout The morning and I took my eyes off it after so not in it now It looks like it finally broke out, right and it looks a lot better now So, you know, this could be on our watch list, perhaps maybe we'll look at like a PLTR XP EV maybe this is like inching back up a little bit Actually don't mind this XP EV here for the time being it hasn't broken a true high or high just yet to get back up towards 17 It's kind of holding under this last peak here for the most part right around 1655 1660 a year If it can make that pop I feel like there could be a better trade on this since it's still up some You know percent and there could be some eyes that catch on to this trade again heading into the close All right, so let me know folks across the board on social media or inside our live trading room Hey, check us out tomorrow as well We have our traders talk workshop live just across the board on YouTube as well as inside our live trading room So any questions you got for me send over it right to my email address directly Josh at c2 trading calm Let me know if there's any questions thoughts comments suggestions, but Otherwise though. Oh, that's right from Donald sing EOS EOS If you can get over 3 30 Possibly possibly possibly possibly and you know what we're not at a enormous list where we're maxed out I'll slip this on there tradeable 100% Just needs to break that 330 it's a good setup and more 3 31 as of now I'd say the opening print Based off the matrix seems to be a 3 31. I don't have my book map open But we'll focus on 3 31, but yeah, I mean that's a good setup. That's a good setup Dressing. Let's go s already on our watch list there. So that's looking pretty decent there, too I'll tell you I think that we pretty much ran our course right now Let me just go to Benzinga Pro lastly see if there's anything looking good from that side Let's talk a little bit about Benzinga Pro heading into our class this afternoon It's not required, but it's something that I personally use so I'll just just slip it in there for like five or so minutes But you know right here SPGC. We'll move up up. We'll move up. No pun intended. I swear SOS we'll take a look at a couple of those No, I went when we're getting this year on the chart. That's not looking good at all SOS is up. Actually 30% I don't know if I skipped over that. It's only trading 812,000 shares this time of the day technically that's more than the minimum that we scan for mind you but You know as I said from class you want to see way more than that at this time of the day So unless if it was just popping right this very instant off of news Then I'll pass on this. It's okay. It's got a big spread anyway. So Rather stick to the eos's of the world that donald s recommended All right, so I'll tell you I think that's all that we got here folks we ran our course. So in total we got two four six eight 10 stocks to work with so you know pretty decent list if anything pretty big So for any of my students joining me in class last call on that rich just posted the link for you right there on the chat board I guess technically not last call. We've got about 20 minutes till we begin 15 20 minutes till we start But hey, I'm going to join class coming up I'm going to step away from the desk here afterwards just to make sure I can get a little Small break away from my desk before class before the end of the day here So I look forward to seeing all of our students joining me at the real five eastern for the phase one course coming up ahead If you're not joining me in class then best of luck trading these picks you're heading into the close You'll hear it from me first though start and stick with this list We just scan the whole market folks So unless if there is anything making an utter pop that you know what i'm talking about unless the stock is doing one of those Let's stick with a aoi. Let's stick with eos. Let's stick with the n ssc on the way down That was a great trick So there's a lot to work with off of this watch list all right folks I'll catch most of us here coming up in class and I'll see everyone at least tomorrow. Take care