Welcome to another episode of GUI Challenges, where I build interfaces my way, and then I challenge you to do it your way. Because with our creative minds combined, we're going to find multiple ways to solve these interfaces and expand the diversity of our skills. And today's GUI Challenges, split buttons. Here is a split button, a primary action, like viewing your cart, you know, the most used action with a tucked away set of secondary actions. So in this case, we have checkout, quick pain, save for later. I think a really good example of a split button that you probably see all the time is the send action, where the send is the primary email action. And you have these additional options to save a draft, delete it or schedule it for later. And I think it's really important that the interface isn't being crowded constantly with all of your actions. They're tucking away some of the secondary, less used actions into a submenu. And if you're getting really fancy, I mean, you can promote things from a secondary action to a main one. Like I think that happens in GitHub. If I often squash and merge, it becomes the primary action. And that's just really nice that the application can kind of give me secondaries as an initial way to introduce me to actions, but then sort of promote them up into a primary one over time. Super cool. So anyway, the split button is full of all sorts of little nested components like we have this pop up, we have buttons, we have SVG, we have hover effects. We have all of that stuff. So you know where we need to go to talk about all that, right? We got to go to the debugging corner. Boom over here in the debugging corner, the safaris on top. Firefox in the bottom left, Chrome desktop, Chrome on Android.  Okay. So I'm going to pop up in the dev tools on Chrome here and start talking about the theme. If you notice, we have a light theme and a dark theme. The light theme is very bright and vibrant.  And on the dark theme, we have a desaturated color set, still blue. We invoke the background and we get a nice dark piece of paper, right? We're in a dark theme. So how do we create these surface layers and how do we create all these interactions? I did it all with HSL. I really love desaturating the dark themes and I really like flipping, mostly lightness. So here, let's open up. I'm going to hit command shift C, grab our gooey split button here. And here's, let's look at the colors. So the light theme down here, you can see we have lights, lots of vibrant colors, a nice bright blue. We're getting into navies and some like light grays, but a few different blues here that seem all quite saturated and vibrant. And then up in the dark theme, look at how they all look desaturated. And we can even look at the values. Let's see. So hue, saturation, lightness, there's three channels in here. These are 75%, 75%. All of these are 75% saturated, which is pretty saturated. And up here, they've dropped down to 50%, 50%. Oh, the theme active is still 75%. So when I'm actively pushing it, oh, look, it even looks a little more saturated. I don't think that's too saturated though. It looks great. Well, anyway, I made the colors so that better be the way, right? That's how I did some of the colors. And these things just get passed around all the way down. There is one interesting concept though here, which is I liked this color here on theme. So that way, and look, this is also not black. It looks very black here. And this one also looks like it's like a really dark gray. But if we look in here, it's 90% saturated. That same blue hue, it just has 5% lightness in it. So it's very, very dark color, which makes it a really rich, dark navy. And that's nice because this is a dark navy sitting on blue. I just think that those always look better when it's not black on blue. You're doing a really, really dark navy. And as long as you can achieve your accessibility contrast scores, which we do on this show all the time with the same technique, I think it just ends up being really, really nice. So there's a couple of color tips in there for how to do in a light and a dark theme. And next I want to talk some of the shadows that are in here. There's some really interesting shadows. So let's go to the light theme first to talk about some of the shadows. The first one is you can see on the button here that the text has a little bit of a text shadow on it. Now the dark theme doesn't have that a dark theme with text shadows is kind of hard to do. I found that if you add a light text shadow to a dark button, it looks like it's embossed instead of where it does here now in the light theme where it kind of looks like it's sitting on top. And that embossed effect can be nice, but that's not really what I'm going for here. But anyway, I thought the text shadow was really nice. When you hover, that background text shadow becomes flat because it matches the same as the hover color. So it kind of disappears. So it's like the text pops until you hover and then it just sort of is. And I don't know. I thought that was cool. Another thing here is if we pop this open, we look at the shadows on this pop up. If you look really closely, it's not a black color. There is blue in there, right? There's a shadow being cast off of this and it's not ever going to be just white or black. There's always a tint of color in your shadows. And so I brought a little bit of our brand hue into the shadow even. And here it is being multi layered on its way down. And I thought that looked really good. And lastly, if we hover on these buttons, we can see a little bit of a text shadow on them. Right. Let's see. Yeah, just a little bit of a text shadow there. And I thought that turned out really nice. Now, the dark theme does have some text shadows. We use a shadow here. So notice the shadow as this pop up, pop up, pops up and look at it layer on here. So it's a really dark blue color similar to the other one. But it's it needs to be a little bit more dramatic to sit on black, but it also needs to sit on the button. Anyway, I thought that just turned out really nice how that worked. And if you look at these buttons, when they're not hovered, they're getting a little bit of that text shadow. Also, the icons have a filter drop shadow on them so that the shadow can follow the shape of the SVG. Turns out looking really sweet. So those are just a few of the shadow tips in here. I think there were little details that end up going a long way and making this thing feel really refined. And you can find all that code in the article, the colors and the shadows. I think they're just ready to take if you want. But always think about HSL and how you can how you can bring your brand color into these little thoughts here. And speaking of little details, we got to talk about some of those SVG little details here. Let me let's invoke this button with the let's see, hover focus within. Yeah, OK, so now I'm going to Command Shift C and find the SVG in here. I'm going to go to the SVG. OK, I'm going to stroke stroke down. I'm going to scroll down. Oh, that's so funny because I'm looking for stroke line cap, stroke line join and stroke width. So the width by default might have been like one pixel. And I was like, oh, that's just too thin. Let's give those a little bit of a boost to two pixels. Now, critically, I have stroke line cap and stroke line join set to round. And let's talk about what that means and how it works. So let's go bump up the size of our icons so that we can see our changes here. Excellent. That looks like it's plenty. Now I'm going to go turn off both of these and talk about what I see. And maybe you already saw the difference, but look at the line end here. So this is the line cap. And now we have a sharp ending right here. And if we look down on these ones, see, we have two little sharp endings on this horseshoe. And here we have a pointy connection point where these are joining. Now, what we do with round is we're telling both of these scenarios to round out those edges and watch what happens. Look at that. It's just a slightly softer edge and overall icon effect. And I just think those little things can really make a big difference. Let's go back down to two characters. And that was just a small tip about SVG. I wanted to share with you. I thought that was really important. That combined with the filter drop shadow just made for a really cool effect. I thought even more little details continue to go into all of the states that this thing handles. So let's check out the state. So we have like a dark and light theme. We're going to, of course, have reduced motion and we'll cover that in a second. But let's talk about all these different interactions that need to happen in here. We can see that there's a hover effect. If I click, there's an active effect. And here it is in the dark or in the light theme.  And I think also, in my opinion, clicks and hover events should increase contrast. So if you look to see like what I'm doing here, I'm trying to make sure that I work and hover towards a color that's going to make the button more legible instead of less legible. Anyway, I think that's just an easy mistake to fall into sometimes. And to get all of these effects in a full view here, let's open up our special little like state emulation tool and DevTools, which I love and just click through some of these. So let's go to the button and the button's going to, of course, have a hover effect and we can see here's the hover changes right here. We have a theme hover color and a theme on theme or color called on theme. And that's giving us a nice contrasting color. If I hit active, we're going to set the background to something a little bit brighter so that you can see your interaction there as a user, right? As you're clicking or you'll see as you're using space bar from a keyboard. Okay. So we'll get rid of those. We also have focus within. And so focus within is being used on this one. Focus within is going to prompt the pop up at which point we let's pull this down a little bit. We could dig in and see the pop up here. Yes. Right. So if the gooey pop up button is focused within, then find that pop up itself and bring it in. And so we're setting it to translate zero. It's opacity one. And we're giving it a speed and that's how it's showing up that way. Also knows pointer events is set to auto because when this thing is hovered out, we don't want any of those buttons to be interactive, right? That would be a bummer, which they are by default. I have to go turn those off. So if we come here to the pop up, we can see that it has pointer events, none opacity zero, right? Because we want these things to be not interactive and needs to be invisible. And look, I can hover on the buttons right now. And we also want it to be not interactive. So kind of tricky, but that was just a small thing to get in there. And I thought it turned out really nice. It was pretty easy to manage. So let's go back to invoking our focus within on our buttons and then find our way down here into some of these buttons. Because of as these get hovered, look at their state. Oh, look at their styles. Oh, nice. We can share some of the styles down here and hover and active. Excellent. See those pop in. And we have focus visible as well. I think we skipped focus visible on our upper button here. Let's check that one out. Focus visible. I liked this focus visible state. We can go look at how I did it as well, because I used a outline offset of negative five and negative five was kind of nice because instead of me trying to hit focus and have it crawl outside of my little viewports here, it's going inward and it still has a lot of contrast. And so it's able to not leak outside of the container. It's in while still providing nice ample focus. I thought that turned out really nice in this particular component to have this sort of inner offset for the focus. So that is most of the styles here, I think for like emulating the different states that we have the different interactions. We've seen a lot of the mouse interactions here. Let's talk about and show some of the keyboard interactions. So here, if I tab into here, you can see my tab focus. We were just emulating that, but now it's actually tapped because I used my keyboard to go in there. So it knows that it should be showing me that focus. That's the difference here in focus visible. If I hit spacebar, you can see me invoking those buttons. That's kind of nice. And if I hit tab again, I'm using my roving index library. My roving index library looked for focus to hit this element. And then it's going to forward focus into this button list. And we'll do the screen reader flow in here in just a second. But now inside of here, I can hit up and down to go through my buttons. I think you can also go left and right. Sure can can go up and down or left and right and find the button that you want. You can hit space to hit it, space, space, space. You can enter to hit it, which doesn't show the prompt, but it does push the button. And then, of course, you can hit escape. And if I was to come over here and hit escape to bring up the console, look, we can see all the buttons that I've been pushing. So there's definitely JavaScript waiting and is aware of these don't hear you, Kurt, is aware of what button is pushed. So, I mean, of course, you're going to need to take some action, right? So that's all handled in my JavaScript. But the roving UX, I thought was really nice. And what, you know, just that kind of cool feature that we got from other episodes is it saves its state. So here I have delete as the secondary action already focused. If I go back into it, it's still focused. So it's going to remember where you were. And that's just cool stuff, right? So we covered keyboard. We've covered mouse. Let's reduce motion. Let's say we'll pop up in here into the rendering tab. We'll scroll down. We'll say reduced motion. And here we'll emulate the light color again, just because it's nice. So we saw before that when we weren't emulating reduced motion, we were getting a slide up card here. But now it's just going to fade in. We're just getting a simple crossfade. So no motion, but we're still getting an animation. Now I left this as spinning still. And I thought that was just something that there's not motion here that's going to create a sickness. I didn't think this wasn't a sort of scrolling or a big amount of surface area that has motion. So I thought it was nice to leave that in there. Now, someone can comment and let me know if that's not going to be OK. But from my research and the folks that I know with this, a small icon rotation should still be OK. So let me know in the comments what you think of that design choice. Also notice that the if I don't emulate motion that it animates in at a different pace that it goes out. So I thought that it was really nice to sort of bring in something very calmly and slowly. It still has a nice pace, but then to dismiss it very quickly. But I don't want to dismiss it like instantly. I just wanted to have like a nice slow, I don't know. I wanted to be able to tell that it was dismissing, but have a nice slow introduction.  I didn't do any color animation. I just have instant color animations, like interactions, because sometimes I like those a little bit better and they're a little bit less for like the GPU to do. So the user is not really going to care if there's like 300 milliseconds of hover time here. They're just going to make sure that the hover is there and that they're getting some feedback that that element is interactive. It has states like click states and it lets them know that this is a button. Speaking on whether or not and knowing if something is a button or not, let's check out the screen reader experience. I'm going to hit command F5 and invoke the macOS system one and try out the UX for the split button. Leaving DevTools, entering split buttons, GUI challenges web content. View cart button. Check out button list three items. You are currently on a button. To click this button, press control option space. Quick pay button save for later button. View cart button. And that's it. As we tabbed into it, we were told that it's a button list and how many buttons are in there and it did that based on some HTML and a few attributes. Save for later button list three items. You are currently on a button to click this button. Press control option space. Quick pay button. Pretty cool. Someone hit escape and close that and hit the hot key to turn off the screen reader. Voice over off. Even more detail can be put into this though. We are not done. We can handle right to left. So if I pop in here and I go to the top of the document and I change the direction here to right to left and hit enter, I can see that my button, which is using logical properties and a few other things is still usable. And look our icons have changed sides. I didn't do that. That was just flexbox. This button even being on this side changed because of flexbox. I didn't do that. I didn't have to change order or anything. What I did have to do though is make sure that I specified the rounding corners appropriately per logical properties so that this could be right to left to have the right borders and left to right to have the right borders, even this border side here. Let me inspect this. We'll go to this. Can we pop up a button? Let me take out the hover states. Let me close the console, pull open the styles more, scroll to the top. And we're looking for border inline start. Here it is for border. And if we go look, this is probably like one pixel solid theme border. Yep. And so there it is. That's instead of using border right or border left. I used border inline start. And now as I flip the direction on this from right to left and left to right, I don't have to care. I actually got to deploy less code and think about less stuff while reaching more people. And that is the power of logical properties in CSS. So that's how I handled that. And the pop up does use physical properties left, right, top and right. So if you wanted to do something a little bit smarter in here, let's go to right to left. In this mode, you could the pop up is locked to the box that this button is coming up inside of. So that's why it doesn't look like it's too far off here. This looks like a fine layout. And I thought it was fine. So you could though, write a media query and adjust this if you wanted to and make it a little bit more specifically positioned. So that's how I handled right to left. I got it mostly for free with flexbox. I love it. Speaking of flex, we got to go check out these layouts that are in here. So let's just check out one of these buttons. We've got the GUI split button. It has displayed flex already. So here it is display flex. And that's it for that style. Let's go to the layout panel actually and kind of hover over these individually, right? So okay, so here's our split button. That was not a whole lot of looking doesn't even show any alignment items in there because it's just a flex. And it looks like it's just making these sit next to each other. And we get the directionality for free and right to left. Okay, every button is a flex layout. That makes sense because especially because you're going to want to align item here, let's go to it. We're going to want to align items and put some gap in there between our icons. Yep, there it is. So here's our gap. And here's our align items to again display inline flex. Okay, let's go back to the layout panel. Let's look at the pop up button. Okay, so that one looks like it has some padding and probably some alignment properties. Let's go to the styles here, display inline flex as well. Align item center justify content center. So it's getting a centering here. Oh, look, we can hover on these to see. They're affecting our align item center and justify content center. Excellent. And let's go ahead while we're here and pop open the states and go focus within because we're going to want to look at the layouts of the pop up here. So here is a gooey pop up, right? That's a UL, right? This is a list of items. And we have no gap between them because look at the hover here. Well, it's pretty much going edge to edge for each button. Let's go look at the styles here. Styles we have, we've got display flex, flex direction column. Oh, that makes sense. And that's it. Again, a pretty light amount of layout styles being done here. This one is positioned absolute. So I usually don't position things absolute in this show or just in my UI in general. But this one ended up being an easy exception because the whole pop out is coming out of this little button here. It just seemed really nice to anchor them. It just felt anchored to the element. So I'm going to position it absolutely and anchor it to an element. It seems kind of straightforward. And the effect was really easy to manage. And I liked it. Okay. So let's see, layout panel probably got one more to look at here. We have the gooey, I know there's just buttons inside of there. So it's just a flex list, a UL flex list of buttons. So really there's like three or four very, um, essential display in line flex layouts that power this entire thing, except this one here that put them in display in a column. I mean, that was not that tricky right here. We go flex direction column. Let's, let's change the direction here to row. Ooh, I know that's interesting. A little pop up row of buttons. That's actually kind of neat. I could totally get behind that. Anyway, there's the direction that we originally set it to. So those are all of the layouts that are done to create this. And I thought that they were really kind of digestible for the first time. Um, everything was really nice. And we got a really powerful layout back. Let's change this back to the left to right. Left to right. Excellent. Well, now's the point of the show where we got to leave the debugging corner and go check out some of the JavaScript that powers these interactions, follow me to my IDE. I used two of my utility libraries to kind of help me, um, make this code a little bit more succinct today. The first one is called bling bling. And really it just gives you, it gives you this dollar sign, which makes selecting elements easier, putting some events on multiple elements easier, and it just has like a couple of conveniences that are sort of leftover from the jQuery days. And then we have this one here called roving index, which we've talked about on the show before, which is what's maintaining and enabling a roving index UX on that pop up. So the first thing that I do is I go grab the split buttons. So this will grab every one of the buttons on the page. And this will grab all of the pop up buttons. Now for each pop up button, we want to give them some roving index, right? So when that pop up button is focused, so here's the element. This is the pop up button itself. Uh, we forward the focus to these targets, to these buttons, and then the tool will maintain all of the different state inside of that target set. So that's how the roving index was set up. We also want to support that escape key. So on the pop up buttons, we're going to watch to see if escape gets pressed. So this is the thing that's prompting the pop up itself. We're watching for the escape bubble to sort of like come up into the parent element here. And if we see the character code as escape, we're going to blur on this item itself, which will, uh, remove focus within and therefore close the pop up kind of neat. Here's another one where we're explicitly on focus in setting some attributes, uh, so that a screen reader can still reflect the accurate state of the pop up, right? Someone can't see. So you have to set the state to expanded and set the expanded state to false, um, when it's opened and closed, that way someone who can't see, right, again, uh, can acknowledge and know the state of this element. And then last year, this is just some demo code to watch for clicks on these elements, but we're watching the split buttons and on click. Um, as long as the node name here is not equal to a button, we're going to, uh, load and console log the target text. So this is just saying like, Hey, the, you know, play button was pushed or the send button was pushed. And, um, this is filtering out anything that's not a button since we're using bubbling, we're watching for all the clicks. You could click on the very edge of the pop up and, uh, this wouldn't invoke any button texts because well, you didn't, you didn't click a button. So the JavaScript, it wasn't that, um, complex or a whole lot to put down, but I think it did add a whole lot of value, right? We're adding some unique things to, um, keyboard interactions with the escape key. We're adding some unique attributes for screen readers. And we're also tying in our clicks and making sure that we're getting some, uh, nice experience for mouse and keyboard users alike. And that is the end of this gooey challenge. I hope you liked the split buttons. Now it's your turn to fork, like, subscribe, do all that sort of great stuff, interact with this content, leave me a comment and show me how you would do it. I mean, that's the most important part here. You need to tell everyone and show everyone how you do it. What is your style? All right, y'all see in the next gooey challenge.


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This is the Big E, the first nuclear-powered aircraft carrier, one of the truly great scientific accomplishments of modern time, a testimony to the wonders of the technology of modern industry applied to our nuclear age, carrying the American flag around the world. By 1954 the Korean War had ended. Eisenhower was president, it was also a time of growth and consumerism thanks to a post-World War II economic boom. The story of the Navy's largest, fastest ship also began in 1954 when Congress authorized the construction of the world's first nuclear-powered aircraft carrier and one of the greatest engineering tasks of a generation. The ship was named Enterprise. In October 1962, Enterprise sailed to its first international crisis. The Big E and several other ships set up a quarantine of all military equipment under shipment to Cuba. By October 28th, Soviet leader Khrushchev agreed to dismantle the nuclear missiles and bases in Cuba, ending the Cuban Missile Crisis. In 1965 she became the first nuclear-powered ship to engage in combat, launching aircraft against the Vietcong. She set a record of 165 sorties in a single day. On the morning of January 14th, 1969, a rocket loaded on a parked F-4 Phantom exploded. The explosion set off fires and additional explosions across the flight deck. 27 men died and 314 were injured. Over the next few decades, the ship endured several drydock periods and numerous scheduled deployments. In the fall of 2001, Enterprise aborted her transit home from deployment after the September 11 terrorist attack and steamed overnight to the North Arabian Sea in direct support of operation enduring freedom. Aircraft from the Enterprise delivered over 800,000 pounds of ordnance during the operation. In January 2011, Enterprise became just the fourth aircraft carrier in naval history to record 400,000 arrested landings. The oldest active warship in the US Navy's fleet since 2009. The biggie was home to generations of sailors. More than 250,000 men and women have served aboard this floating fortress. For 51 years, US Enterprise has proved she would answer the nation's call time and again, upholding the legacy begun by the first Enterprise sailors more than two centuries ago to defend freedom and democracy around the world.


Ladies and gentlemen, welcome to another video, Silent Mike here, Nature, that's why I come out here. I'm talking about health. I'm talking about food. I'm talking about eating out. We love food. I love food. Hopefully you love food. We're going to talk about how you can eat a little bit healthier out here at Mickey D's, America's Goodness, America's lovely fast food chain that's been around forever. Have you seen the movie Founders? Amazing film. Highly recommended. Backstabbing sons of bitches. We're hungry for money. And I get it. I want money too, but bring your friends along. And I guess they try to give them mixed feelings. I guess you guys have to see the movie. I have mixed feelings on who was in the right and who was in the wrong. One wanted to keep it mom and pop. One wanted to make a lot of money. They wanted to scale it up with them, but sometimes you get left behind, I guess. Don't get left behind, I guess, Mr. McDonald's. So when we're talking about healthy eating, healthy foods, I don't like the term healthy because, again, we have to start to have the same conversation. Everyone's talking, but we're having different conversations. We're talking about maybe what's healthy and maybe how you can lose weight. And so, of course, when we're talking health, general health, longevity, feeling good, making our bodies function well, we need to talk about micronutrients, vitamins, minerals, all these things are better found in fresh fruits, fresh vegetables, and homemade food most of the time. So when we're talking healthy eating at McDonald's, no, it's probably not the first go-around.  But when we're talking about calorie deficit, when we're just talking about losing weight, feeling good, getting a little bit of protein in a meal in, we might be able to do that at McDonald's. And that's what we tried to do today. My fitness pal, a lot of different apps online, can allow you to track your food very easily. You can be a little bit flexible with it. Overall, does it have the micronutrients of a fresh steamed broccoli and steak meal? No. Does it have a little extra sodium? Yes. But, again, everything in life, moderation. Growing up as a kid, mom worked late every Wednesday. And I don't know if my parents had this kind of power.  But maybe they had a conversation with McDonald's because every Wednesday for a while there, a hamburger was $0.25. I don't know if you guys remember that. And this isn't the old, I used to buy a hot dog and a soda pop with a nickel. This is 2000, probably year 2000, maybe late 90s. There was hamburgers for $0.25, I think just a quarter. So mom worked late until like 7 o'clock. I think dad, he always worked overtime. He would pick us up from like daycare or school or whoever was babysitting me late after school. I was probably 18. Just kidding. I was young. So we were being babysat or watched or whatever. We got picked up at 7 o'clock straight through the drive-thru. Not only did we get 25 cent burgers and I get like five of them growing boy, we also the Monopoly game. If you don't know about Chicken Nuggets, 25 cent hamburgers and playing Monopoly on the newspaper of McDonald's, you can get on out of here right now because that is America. That is my childhood. So this is like half of what I typically get. Look, I love a vanilla cone, but I got to go work out later. I love a McFlurry. I love all that. I love me a Big Mac. But we're trying to do moderation, trying to get to it. We want small fry. Great nickname. But I want small fry. This is the go-to.  When I'm talking about nostalgia, when I'm talking about the old good of a McChicken, I love one of my favorite foods and you guys can make the bland taste bud joke all you want. I love a good chicken nugget or a chicken strip from anywhere. Dip it in a little barbecue, dip it in a little ketchup. I absolutely love chicken. So I would rather have McNuggets, I guess was a long story short. But what we went with is the grilled artisan. Got a little bun here. It actually looks like a fancy bun. They're trying to make it look artisan, which means high class I believe here in McDonald's talk. It looks a little plasticky, but I've had it before. It tastes decent. Lettuce is looking a little sad. If this lettuce had an emoji face, it would probably be frowning. We have a tomato that actually looks pretty fresh, considering we're here at Mickey D's. Tomato looks fresh and to be quite honest, the chicken breast isn't looking too bad. So I'm going to take my wilted salad out of the picture for nostalgia. Why did you put it upside down? Look, I know you guys are getting paid not much. I know you're probably in high school, but just put it the right side. Don't they know that we're coming here to make content? When you order a hamburger, anywhere else in the world? You get such a little hamburger. A total of 20 chunks of onion, one pickle off-centered, seven dollops of mustard, and a nice squirt of ketchup. Little did they know. I guess they read minds. I love ketchup. I'm not a big mustard guy. I forgot to order it.  But we're going to ignore that for nostalgia. Overall, probably a medium, moderate carb meal here, a little bit higher carb with these fries, but you've got to get fries when you go to Mickey D's. Come on. The chicken and the burger together, decent amount of protein, probably 50 grams or so. And then the fat, again, moderate. The burger's a little bit higher than the chicken. This chicken, if you want to go real low fat, you could hammer a couple of those.  Sodium, again, if your sodium is in moderation day to day or meal to meal, you'll probably be okay. Yes, this is a little bit higher dose than a home-cooked meal. But if you're not eating this three, four times a day, you'll probably be just fine.  That's what we're about here. I don't know who made the standard of burgers, but I believe the standard is what? Quarter pound, third pound, half pound burger. I'm not a scale, but typically it's just by the meat. And I think this entire thing is probably less than a quarter pound. That burger's, I don't know, centimeters well, but it's like an eighth of an inch thick. Normally a burger also, you can kind of order it how you want, right? Like medium, rare, rare, well done. And that goes by the color that's on the inside of the burger. We're just going to ignore that for this burger. I don't even want to look inside what type of color we have going on, but it's probably a nice grayish hue.  Mike, they'll survive an apocalypse. You could throw that thing in the ocean and it'll come back and it'll be fully together. It won't absorb any water. Oh, that thing will outlive a cockroach. Oh, that thing's full of nuclear power.   But if you haven't known that, I'm into it. Now, we're talking French fries. It's a hard rating to give when we're talking about pure taste because there's such a variety of fry, right?   Those are some of my favorites. A lot of seasoning, a lot of crunch on the inside, some soft on the inside, some crunch on the outside, some soft on the inside. I think that's the goal when we're trying to get to any French fry. Steak fry, right? You want a little, it's obviously fried, so you want a little crispy on the outside, but the inside real potato-y, the diameter of the curly fry is a little bit less, so you don't get as much softness, but you can still sense that the outside is protecting the inside morsel of warm potato. Now we're kind of going to the regular French fry world. Things do become a little bit more bland, and that's when the ketchup gets involved.  McDonald's still reigns the king. They still reign the king. It's a quality French fry that will tickle your taste buds with consistency every single time you order it. Is it the best fry in the world, though? Is it consistent and nostalgic?  On an anabolic scale of fast food, the fry is probably like one out of nine. You know, it's a little good pre-workout, I guess, because some salt can give you a little bit of a pump, but talking about macro and micronutrients is probably not the direction we want to go. Moving on to the burger, I probably haven't had a McDonald's burger in, let's count it a decade. It's probably been a decade. First thing you notice is that the bread, although it looks very fake, tastes pretty decent, and you get a nice, you get a nice mixture, even though they only have five onions on there, one pickle, a dollop of mustard and a wad of ketchup. It is actually a good balance, a good ratio. What I would say is the ratio of bread is a little hot. When we're talking total taste, again, we have to talk about, we're almost below one a single ball, because this is the sad representation of a burger. There's no real meat. I'm the guy that wants at least a two to one ratio of bread to burger, and this is probably like a five bread one burger here, so one that brings our scale a little bit down, two it's in a different league, right? You go Big Mac, at least you got double burger. I guess when you go McDonald's, the general rule of thumb is you should probably always go double patty just to make up that ratio, because if you don't have that ratio, I don't think we can call it a burger. I think that's what we're getting at. So, whatever it is I just ate, even though the ratio of flavors taste okay, the texture is not, there is too much bread. On a scale of one single A, fast food burger, the most basic thing, this is probably the first thing McDonald's ever made, whatever, in the 50s, 60s. We're going to give it, we're going to give it a 4.1 out of 8. 4.1 out of 8. On an anabolic scale, considering that my body probably cannot digest or absorb anything I'm eating, besides maybe this chicken breast, it's probably going to also be a 1 out of 10. It's going to be a 1 out of 10 on an anabolic fast food. Very least, if I put a different logo right here, and this said Mike's mom and pop, artisan chicken sandwich, and you guys opened it, I think it's believable. Besides the one random french fry that I spilled in there, and the wilted lettuce, this is a believable sandwich that you could get at a reputable place. And I'm not meaning here to bash all the McDonald's lovers.  The taste overall is still solid. I mean, we just bought half of the menu, and it cost me $10. There's some miracles in McDonald's, but I actually like food, all right? I actually like food. I'm not a chef, I'm not a professional taster, although my mom does have a professional palate, so it's in me somewhere. I like good food, I think I have a good taste buds. I think I know what's good, what's bad, what's shit, and what's decent. And on the scale of chicken sandwich or the scale of burger, we know what we're dealing with here. That's why I'm putting it out there. Let's all step into the same league. We can't compare apples with oranges, even though some people can if you're saying your favorite fruit, but beside the point, let's dig in. My fault. We'll get there. There you go, it's my fault. I won't chew this way. Now people, have you picked up the latest glamour magazine, shape magazine, men's health, whatever? Oftentimes, they start talking about the devil in the sauces, right? There's condiments. There's a lot of calories that we don't necessarily need. Lucky for me, I'm not a huge fan of condiments in general.  Not a male guy, not a mustard guy, even though mustard's not that calorie dense. I'm not big on sauces. So this normally comes with a vinaigrette on it, and I think it's an aioli of some nature. Aiolis typically are pretty fatty, so I got no aioli. I guess overall it's a bad choice. That was a little bit dry. McDonald's so good a fly will eat it. It's a little bit dry without the aioli. So I guess if you guys want to be flexible in your dieting, probably keep the aioli in there just for texture reasons. But overall, it's a good ratio. The bread's a little bit better than this bread. It takes a little bit more real. And the chicken itself, although dry as dirt, tastes like I just bit into a poor pigeon that's been walking through the Mojave Desert for 10 weeks straight, not a drip of water, trying to get a drip of water from some cactus. But it tastes like chicken. At one point, this was a real chicken. I don't know how long ago. I think that's the real issue here. These flies are really trying to get on my Mickey D's. Don't touch the Mickey D's nuts, right? No? So they're pretty, it's pretty good. It's pretty good. And this is typically, I've probably been to McDonald's four, five times over the last year or so. But one time I had to get the chicken nuggets from my kid, from my childhood, the inner mic. I love chicken nuggets. But the other times when I'm trying to eat a little bit healthier, I do go here because it's good amount of protein. Taste like, you can look at that.  It's fully cooked through. It's a real chicken breast. The bread's actually really solid. And I showed you that tomato. That tomato was rock solid. Now what I forgot to do at McDonald's, I think they have a new burger out. It's supposed to be premium. They say it's like real beef. Like, oh, then what's this other one, right? We should have got that to try it, but that about wraps it up. On the taste of, let's throw this into the big leagues.  He's ready to go to the big leagues. So all chicken sandwiches across the world, scale out of 10.  It's still a four out of 10. Could I go to a random cafe and probably get a better one? Yes, that's probably gonna be the five out of five. But for the convenience, for the price, for the memories, the history of the drive-through factor, four out of 10 is not bad, Mickey D's. On the anabolic scale of fast food gains, the artisan chicken sandwich gets a seven out of 10.  That was what you were looking for. I'm not too happy.


All right, so welcome to the spring part of our lecture series. We're back to our Wednesdays in person. And we do have a number of in person lectures coming up in the next few weeks. So I'll just remind everyone. Today I'll be introducing Dr. Anna Volerman is speaking today, followed by next week, Carl Street, who's a physician and graduate of the University of Chicago. And we'll be coming back to visit with us and then followed by Pringle Miller, who also is a graduate of the University of Chicago, also here locally and will be back with us. Followed by April 12, a panel of our local female surgeons who run the Department of Surgery women's committees just a discussion of the state of women in surgery so really excited for the upcoming events but with that I'd like to introduce Dr. Volerman who be speaking today and Dr. Volerman is an associate professor in medicine and pediatrics at the University of Chicago. She's a primary care physician for both children and adults and a health services researcher, focused on reducing inequities. Her work applies community partnered research and implementation science with the goal of reducing long standing systemic and structural factors that drive health and education disparities in communities. I'm passionate about increasing representation and diversity in the biomedical workforce. I work closely with her and she is a subcommittee chair in the Department of Medicine women's committee, and I think we'll hear about her work today with Dr. Laura and some of the work supporting women here at the University of Chicago so welcome Dr. Anna Volerman. Thanks Julie, I have to adjust the mic appropriately for height differences that might arise. So, thank you all for the opportunity to be here today, and I'm excited to have the chance to talk with everyone about gender equity and caregiving. I think to start, I want to kind of set the foundation that we are all caregivers, where we will all be in need of caregiving at some point in our lives. These are incredibly powerful words by former First Lady Carter, who indicated there are only four kinds of people in this world. Those who have been caregivers, those who are currently caregivers, those who will be caregivers and those who will need caregivers. Caregiving is universal. And so I think no matter who you are, no matter what stage you are in your life, caregiving is something that will be a part of your life if it isn't already. And I think important kind of to bring that foundation to the discussion today. So in terms of disclosures, the work that I'll share today has been funded by the National Institutes of Health and by the Walder Foundation. I think an additional disclosure that the information that I present today come both from my experiences as a faculty member for my work with other faculty, staff and trainees, but also myself as a caregiver for three young boys. And in that process, I've had support from my parents for my caregiving, and now have recently become a caregiver for my mother in the setting of my father's recent death. I will acknowledge I have been very privileged and lucky in my caregiving journey, and not everyone is. And we'll bring that to the discussion today. So to get started or what I'm hoping you'll get out of this talk is really just understanding what is caregiving and who are the caregivers. How caregiving impacts the work that we do as physicians, and why it is so important to support physician caregivers. And then also consideration about the approaches that we can use to fix not just individuals but to fix the system to support caregivers. Thank you so much for the caveats for the presentation today. I will discuss gender, and I acknowledge gender is not binary, but for the purposes of the work presented today, many of the studies have been done using gender in a, in a binary way, and I will share what has been published in that regard further data and evidence about race and ethnicity, as well as individuals who identify as LGBTQ is limited. And only what's available will be presented. So to start, what is caregiving and who are the caregivers. Sorry, I'm thrown off because the font looks completely different. So to start a caregiver, you know, if you, if you open up Google and you look up the definition for caregiver, a caregiver or caregiving is the activity or the profession of regularly looking after a child, or a person who's sick, elderly or disabled. And most commonly this caregiver is assisting with impairments that arise as a result of age or of disability or disease. Now in our minds, caregiving may bring a very different concept depending on your professional or home situation. I want to acknowledge terminology because there's quite a bit out there when we think about caregiving right as physicians, or as clinicians we often think about caregiving from the perspective of caregivers or home health aides that support our patients. As parents we might think about nannies babysitters and AIDS, and that that the terminology used for that is a formal caregiver or a paid caregiver. What we'll talk about largely today is informal caregiving, or that that is, that is the role of a parent, a grandparent, a sibling, a friend, a neighbor, a guardian. And I think also acknowledging, I will use the term either informal caregiving or family caregiver throughout the discussion just to be clear about these distinctions. So, who are the informal caregivers and it's, it's interesting because there's very, there's there's not a lot of data out there that says X amount of people have informal caregiving responsibilities in the US right. So we're very kind of stratified in our studies. And so to start kind of thinking about who are the informal caregivers for children. This varies quite a bit based on age of an individual, as well as their gender, but it's estimated that about 86% of American adults who are over the age of 45 have children, and so have caregiving responsibilities. In the US households 40% have a child in the home, whether that's a biological child a step child or an adopted child. And when we think about families who have children, at least one parent is employed in nine out of 10 families. And in about 60% of those families where there's a married couple, both parents are employed. I think also importantly to think about gender here. When we think about who's participating in the labor workforce, and this is broadly not just among physicians, about 70% of women with children participate in the labor workforce in 2021. So we've come a long way in that and we exist in a system that was largely not built for women in the workforce and so that's what we'll get to you today. Informal caregiving for the elderly, or those who have diseases or disabilities. This is actually much more quantified in the literature, because of the focus on elderly that has that have been that has been done. So informal caregivers provide up to 90% of long term care within the home for adults. And currently about one in five Americans are providing unpaid caregiving to an adult who's either elderly or has health or disability needs. 60% of these individuals are women, typically mothers daughters and sisters of the individual. And these numbers will likely continue to increase because of the aging population we have in our country. And it's estimated that that the economic value of this unpaid caregiving that's provided is over $500 million billion dollars per year. I want to take for a minute and lump these two together so the informal caregivers of children and the informal caregivers of elderly. Kind of you lump together and this is often referred to the sandwich generation, this most often affects individuals who are in their 30s or 40s. And they're individuals responsible for bringing up children, as well as caring for aging adults. It's estimated that nearly a quarter of all adults fall into this category, and over half of American adults in their 40s doom. These individuals often face higher burdens, because of these, these, the needs that exists within the home as well as the emotional and financial aspects that come with this care. This picture will hopefully in this image reminds me often that caregiving is not just something that affects individuals when they have children, but it really again affects us all throughout our lifespan and throughout our career span, when we think about physicians. So, to talk to really think about focusing this conversation on physicians. There's actually limited information about how many physicians are caregivers. There's actually limited information about how many that was done really focused on physician mothers, right so already physicians, providing care to their patients and mothers providing care to a child. And 16% of those 16% of those individuals were also carrying somebody with a significant health condition. You can see nearly half of those were parents. And, but in many cases there was other relatives even friends and children. And individuals were older. And I think that you know the term often used for this group is actually individuals who are triple caregivers, really caring for patients within the health system, children, and elderly or ill individuals. So, with some, some insights on what is caregiving and who are the caregivers. Let's talk a little bit about the impact of caregiving. So, some may say, like, well, caregiving that happens in the home. And how does that really relate to what happens here within our institutions or in other clinics or academic institutions. The reality is it's impossible to celebrate separate work at home. And so it's important to think about what's the effect of individuals. I'm going to pull out the study first to start a conversation that was done back in the 1990s that we're talking 30 years ago. And this was one of the early studies that was done to quantify the effects of having children within the home. There was a survey done of Ontario based physicians who were certified in family medicine. And here participants reported their work hours. And also reported the amount of hours spent on unpaid work within the home or domestic work as they, as they term. I think for baseline kind of characteristics, approximately three fourths of these individuals were married and have had children in the home. And women who were in this group were more likely to have a spouse who worked full time rather than men. So when we take a look at this table, what I'd like to do is first start with kind of breaking it down for you. So first they delineate what has the time been spent on, and then they provide the number of individuals that they have data for, but then the mean hours. And that's really where I want you to focus is the mean hours for women versus the mean hours. I'm sorry, versus women in an average week. And so to start, if you start by looking at the professional activities and the time spent on professional activities you can see men with children at home and without children at home spent about the same amount of time on professional activities.  Moving on to the household piece. You can see that not surprisingly both men and women who have children at home spend more time on household responsibilities than those who don't have children. Although you can see that that number significantly larger for women than it is for men or that increases significantly larger. And then the child care piece. Men who have children at home spend about 11 hours per week with for childcare, as compared to zero hours for those who have no children at home. In comparison, women who had children at home spent 40 hours a week, the equivalent of a full time job on childcare at home. And so, you know, not only significant differences in numbers but really eye popping differences in those numbers. So when you when you combine both professional and responsibilities within the home. You can see some, you know, some significant things are some important points for those who have no children at home. The hours spent in total are pretty similar between men and women. However, for individuals who have children at home women spend 22 more hours per week on all professional domestic related activities than men. So some people would say that was done 30 years ago what happens today, or what is, is it still relevant today. And so this is data from a study that was done in around 2010, and it focused specifically on early career physician researchers and also looked at the time spent on both professional work and domestic work. And in general they found out of about 1000 respondents who are all academic physicians. There was a mean age of about 40 90% were married and 80% plus had children. They found that, again, women were more likely than men to have spouses or domestic partners who were employed full time. And then women. So this is looking specifically at individuals who were married or partnered and had children had children women spent eight and a half more hours per week on domestic activities. And that included after adjusting for other factors such as work hours spousal employment and other considerations within the home structure. In addition, I think importantly the study looked at a subgroup analysis of individuals who had spouses or partners that both worked full time, and in that subgroup. When there were situations where the usual childcare arrangement was disrupted, women were significantly more likely to take time off as compared to men in that setting. You know, I, I think pretty significant data both many years ago and in the early studies and also today, or more recently that suggests that women take on the disproportionate amount of responsibilities within the home, and have a total number of hours that are significantly greater and so take on kind of the burden of those domestic responsibilities in the setting of caregiving for children. I think thinking, you know, about this work family conflict that occurs, you know, these responsibilities create conflict, a kind of that that balance between work and family. And for some that does mean transitioning away from working full time or leaving the field all together. And so this is a study that focused on early career physicians across all specialties so they actually enrolled individuals, during their current year at the University of Michigan, and then followed them for several years after training. And they hear this, these results focus specifically simply on whether they were individuals worked full time or not in the current years after completing in the years after completing residency training. So on this table here you can see the number of years that have passed since they finished training so at one year. As far out as six years, and you know the respondents here what about 50% female, the median age was 35, and the median years post residency training was 3.2 years. Overall, women were more likely to report that they were no longer working full time, starting as early as one year after completing training and growing exponentially with each year. So you can see here, even at the first year out of training women were two times more likely to report that they were no longer working full time. At six years out they were 27 more times more likely to report that they were no longer working full time. In fact, at the six year mark, three quarters of women reported that they either had already reduced work hours or considering reducing work hours. So this gap that emerges really early in a person's career is, you know, is, is impactful and that it really sets the foundation individuals who leave. It becomes increasingly hard to come back as you're, as, as you're gone for any period of time but particularly as you've gone for longer, because of there was requirements for regaining your, both your certification, but also your privileges. There's, there's a requirement for explanations for time away from practice, and then also sometimes even shadowing or supervised practice when you return. And so that retention piece within the workforce becomes really important, but also this type of these types of differences early in a career really set the foundation for differences that arise over time. So, beyond, you know, beyond just the number of hours and an overall remaining in the workforce, it's important to think about what are the impacts of caregiving on individuals who do stay in the workforce and this study focused on physician mothers, and compared physician mothers who had additional responsibilities versus versus those who did not. So, looking here. This is, this is a survey that was done. And so this is all respondents and that breaks down to individuals who were simply physician mothers, and then individuals who were physician mothers with other caretaking responsibilities right so also so likely in the sandwich generation caring for a neighbor or caring for a neighbor others. So you can see even for physician mothers alone without additional care taking responsibilities. There were significant impacts both in terms of behavioral health, such as, you know, a third were likely to have a mood or anxiety disorder, or even have risky behaviors such as drinking or substance abuse. These numbers, particularly from the standpoint of depression and anxiety were even higher for those who had additional responsibilities. And then beyond the behavioral health, thinking about impacts on an individual's career. Nearly one in 10 individuals had career dissatisfaction and large proportions, 40% of individuals physician mothers reported currently being burnt out and this was a survey that was done well before the coven 19 pandemic. You know, and we're not been linked with many negative effects, both in terms of patient outcomes, academic productivity, and also impacts on children and their development. And so really, kind of foundational in terms of the, the other effects that can occur. There are many other outcomes that haven't been specifically described in the literature. Oftentimes because they are invisible, they're hidden. Many individuals sit with these or experience them. You know, in the rush of the day to day. Or oftentimes there's challenges with linking physician workforce data with patient outcomes data and so have kind of precluded that piece of it. I think importantly, you know, when we think about these impacts, there's both short term impacts and long term impacts and we're at a, we're at a point where we've reached equity in terms of the, who's entering medical school and who's graduating from medical school, and yet the data very clearly shows that women do not advance and academic medicine, and not because they're not talented, not because they're not capable of it. But because there's multiple barriers along the way, and the disproportionate caregiving responsibilities are one piece of that. You know, and those responsibilities perpetuate the gender gap and then equities and promotion and advancement and leadership and ultimately in compensation. And so I want to, I want to briefly touch base on coven. I think to step back for a moment outside of the physician workforce. The pandemic overall resulted in an increase of informal caregiving, I think not surprising to any of us. 51% of new informal caregivers reported that it was a result directly of the pandemic. There could have been done in this area show significant burdens as a result in terms of mental health from stress and worry, fear of infection, but also brought on by the pandemic and isolation a lack of respite care or other avenues to support child care or elder care or care for elderly. And the caregiving also increased during the pandemic. There was a longitudinal study that was done part of that continuation of that interns health study that I mentioned earlier that looked at two time points. August of 2018 before the pandemic in August of 2020 during the pandemic. And this graph here shows kind of the work family experience that occurred as a result of the pandemic. I surveyed 215 physician parents about half of whom were female with a mean age of 40. And they found that women were more likely to be responsible for child care and schooling. They were more likely to be responsible for household tasks. They were more likely to work primarily from home, reduce their work hours, have greater work family conflict and experience depressive symptoms and anxiety. So, I think, importantly, from the perspective of of thinking about dual employed households, those individuals who were physicians working full time, and also had a full time physician partner. There were greater gender differences in the household responsibilities and childcare overall. And so again, signs that even in environments where there's two physicians in a household together that the women physicians face the disproportionate effects. I think another interesting results of this finding that isn't depicted here is that they actually before the pandemic there was no difference in depressive symptoms among men and women. And as a result of the pandemic in August 2020, they actually showed that women were more likely to be depressed or have depressive symptoms than than men. And so, again, just thinking about that those significant tolls and significant burdens and the impacts of them. There's been growing research into the effects of the COVID pandemic on women. There was a report from the National Academies of Sciences, Engineering and Medicine that that focused on what the impact of COVID-19 would be on the careers of women in academic medicine. And here they surveyed women faculty back in 2020, about six months into the pandemic and found that, you know, nearly a third, nearly 75% of women faculty with children reported negative effects. And that 90% of the women were handling the majority of school and childcare related demands. And I think notably only 9% of these individuals shared that they shared these demands equally with their spouse. And at that time only 3% had helped from a sitter, a nanny or a tutor. I do want to highlight silver linings of the pandemic because it helps me stay positive about the last few years and so 13% of women faculty did mention positive effects of the pandemic on family life like more time together. And I do want to highlight ease in managing work family demands, and even things like not having to get dressed for work. So, I do want to share for a minute here, a survey that we did here at the University of Chicago with funding from the BSD pilot awards that focused on early career investigators. We focus specifically on early career researchers because they're really at a key time in their training and in their careers. And they're also really important to the scientific advancement that's going to happen in our nation right there the folks that are going to bring new ideas and new skills. However, these early career years often overlap with prime family responsibilities both family building child rearing, and there's important considerations that lead to vulnerability and attrition. We did a cross sectional study in 2021 that evaluated both the professional and the personal effects of the pandemic on early career researchers. This was a survey that was sent out to all K awardees nationally. We had about 1500 faculty reply to the survey. And as you can see here. Over half 58% had caretaking responsibilities for children and one in 10 reported caretaking responsibilities for their parents during this time. We asked about the personal effects of the pandemic on early career investigators and found that women disproportionately reported negative effects related to caretaking and mental health. This is very much consistent with the prior literature that I've shared. But you can see here that women were more likely to report negative effects in terms of personal mental health supports within the home childcare responsibilities and elder care responsibilities from a professional impact standpoint. Women also disproportionately reported negative effects on a variety of career measures related to productivity and to output. So women were significantly more likely to meant more likely than meant to report that their overall research productivity was negatively affected. The research productivity for the K award was negatively affected, which is critical for getting the next step of funding, as well as significant differences in terms of manuscripts. Interestingly, we also collected data about grants submitted and grants received, and there was no difference between women and men and that was thought largely to be as a result of where the where the, the participants are in their level of training and that they're really not focused on getting that next large big grant as a whole group of K awardees while some might be that that's not. The entire group. Interestingly and not depicted here we also asked about negative effects from the cancellation of conferences. And that is one area where men were more likely to report negative effects as compared to women. And I think largely because of the networking that occurs at those conferences, and potentially, you know the participation of individuals and conferences before the pandemic. So this survey also had a set of open ended questions and I think some of these are really interesting to highlight, because I think the words of our participants are even more powerful than the words that I can use to capture them. Many recurring themes arose around personal well being and family balancing that with research and its effects on working work advancement or professional advancement. Many pointed out the childcare was a huge challenge that the lack of access to safe and reliable childcare that was associated with remote learning quarantines and even changes in the family routine. And also described challenges with visiting and caring for aging and vulnerable parents. The quotes here highlight that early career researchers had to balance just an overwhelming amount of demands in both their emerging careers and their personal lives, and that these impacts were deeply tied we really can't just fix one or the other. There are multiple interrelated effects. You know, and given the strain of the pandemic, it shows that early career researchers really are a group that need additional support. And it's really important to make sure that we can continue the scientific advancement in our country and ensure that their success. How exactly can we support physician caregivers right we've talked about who they are. We've talked about the inequities there. We've talked about how cove is just made a worse. And so what exactly can we do and before we say what we can do I want to talk about the imperative to do. Physicians and and all individuals must take care of themselves so that they can take care of others right and if our expectation in the in healthcare is for physicians to take care of patients. We as individuals and those institutions must take care of those individuals who are taking care of our patients if we want to meet. You know that aim of healthcare. There's an imperative to act because these disparities persist, and they will worsen. If we don't, you know, frankly, though, the data currently suggest they'll take about 50 years to reach equity. And, and, you know, that that was potentially worsened in the setting of the pandemic. I think if you're driven economically. I think there's also a financial imperative to act, both in terms of the retention of women in the workforce and the cost of replacing individuals. But I think also an imperative for for from the financial perspective of individuals medical school graduates finish training with about $250,000 in debt. And so there's a there's an incredible burden on individuals. And if we're not supporting them and remaining in the workforce and they leave the workforce they're still facing that debt that debt doesn't magically go away. So let's dive first into what currently exists to support physicians who are caregivers and I think when when this question comes up, most people are like oh yeah there's there's leave there's parental leave right like that's kind of the default answer and so that's among the most common structures we have so to start what is parental leave look like across health systems and academic medical centers across the country. And I will say just to summarize, there's a lot of variation. So there's been two great studies done in the past five years that focused on leave policies for faculty that looked at top ranked schools across our country. I will share that these are. This is the data for medical schools and ranks by US News or World Report I will not get into that whole discussion right now. And I will just share that this is the case for faculty and that the leave policies for trainees for staff are often significantly lower or worse and with more variation than they are for faculty. So I think, first to site here, this study that looked at these at the 90 medical top top 90 medical schools as ranked by in our country. In terms of, you know, most policies break this down by parental status and so a quarter of institutions had no paid leave at all they indicated that individuals could use their vacation time their sick time or the short term disability time. The remainder provided some paid leave, and about 15% provided full pay for at least 12 weeks which is the case here at University of Chicago, the median duration of paid leave was four weeks. For non birth parents, over 40% had no paid leave. And you can see the breakdown about 40% had one to 11 weeks. 12% had 12 weeks or more, which is currently the case at University of Chicago. Similarly for adoptive parents 40% of institutions had no paid leave and similar rates had less than 12 weeks and about one, one and nine had 12 weeks of paid leave. And then for foster care 31% of the policies didn't even mention foster care. And the majority had no paid leave, while a small proportion allowed 12 weeks of leave. Notably, you know, there are national guidelines for recommendations for for leave that are put out both by the American Academy of Pediatrics and the American College of Obstetrics and gynecology, the talk about the benefits of paid leave both for the child and for the parents and parents. And so these these as a whole are significantly lower than those recommendations and we know significantly lower than many countries internationally. I will also add that that this on paper is what is cited as the policy and I think it's important to recognize that the implementation of policies can often differ from what's actually put on paper. So I'll tell you a story of a colleague who was a dual physician couple who happened to work at the same institution, and they were essentially told by their institution that they could not take leave at the same exact time. Even at the time of the birth of the child that the leaves could not overlap in any way. And so I think it's important to recognize that while something might exist on paper. It's really impractical for not to have both parents, if they are, if there are two parents at a birth and so I think really important to think not just what's on paper but also what's implemented by different individuals both leadership administrative support human resources and beyond. Thinking beyond, you know, family leave at an institutional level, and parental leave specific thinking beyond parental leave, I think thinking about family and medical leaves. And nationally there's guidance from the family and medical leave act locally leaves very significantly by state by county and by city. You can see here this map from the Kaiser Family Foundation that shows, you know how few states actually have paid family and medical leave enacted. And how one state has simply paid medical leave enacted. And there's quite a bit of variation in terms of what actually individuals can use and I think often limited information available without digging quite a bit into finding that information.  It's either for sick days or for a small number of days. And you can see here there are a few more states that have paid sick leave laws, and that there's also some cities and counties including in Chicago, here with with such laws. And to consider that some of these sick leave laws are acknowledged only the individual versus sometimes they acknowledge additional children or elderly individuals that the individual might be caring for. So going beyond leaves I want to talk about a few topics. Because, you know, the reality is clearly caregiving doesn't just exist in chunks of time, but that it's really something that that is there 24 seven, you know, for throughout much of a lifespan. So first to talk about lactation studies show that about a third of physicians meet their personal breastfeeding goals, and half would have breastfed longer if they were able to, or if it was possible. There are many workforce and workplace challenges cited including inaccurate time in flexibility with schedules and insufficient space. And these peripartum concerns are often opportunities for supporting and retaining and recruiting women faculty. I want to highlight some of the policies at University of Chicago, you know that while exist and meet national laws, you know are quite vague. This this policy is very similar to policies that exist across many institutions. And so making a really challenging to implement. You can also see here, you know various kind of maps and resources that exist, including Mama Vapods that support, you know, lactation. But also important to think about how large of a campus we have and where are the spaces for it and then also how is it enabled throughout the day, everything from during rounds during surgical cases. During busy clinics, you know how is it made possible. I think, in addition to that, even just recognizing things like lactation support services, while seemingly not profitable are incredibly important from an institutional standpoint, and currently here at University of Chicago don't exist in an outpatient process. And so, there are ongoing efforts between the women's committees in the departments of surgery medicine and pediatrics, working with the fact to really advocate for demonstrated support for women who are laxating, both in terms of the resources necessary, but as well as modification of duties and appropriate, appropriate adjustments in productivity and compensation as a result. So let's first, let's next talk about childcare. There are nationally very few places, very few academic institutions or health systems have childcare present on campus, University of Chicago is unique in that about 10 years ago they invested into childcare centers that I know my kids have been lucky to benefit from and I know many of our faculty here have been. The broadest investment is incredible I think it's important to acknowledge that daycare centers are necessary and not sufficient. Some individuals choose in home childcare, and the workforce for paid caregiving, often tends to be focused on women and it's important to think about what support is being provided in that regard because it can be incredibly challenging to find and retain long term childcare, particularly in the setting of long and unpredictable hours that physicians have, including weekends. And also beyond the day to day care.  Because oftentimes these are expected and unpredictable. I recently was talking to a neighbor of mine and just set us simply how are you. And he responded to me, we're built on sand and I kind of looks at him like what do you mean. I'm referring to an ongoing challenge that they had with the childcare arrangement they had a nanny. They had one of their kids and daycare right and I will acknowledge lots of privilege. But really depending on what foundation you have and what happens, it can really just simply take a gust of wind, or a large tide to blow away kind of the foundation. He and his spouse were both employed full time, including one of them as a physician, and they had two young children and their nanny was facing a family illness. And in that setting, their typical childcare arrangement was abruptly, you know, pulled out from under them. And they were scrapping together backup childcare and recognizing that could get pulled out in any moment. And so even with a lot of privilege and in hand. They had a bit of uncertainty about childcare. Here you can see a text thread among myself and other colleagues, where, you know, it's, it was one of these times where somebody had something pulled out from under them their, their child was sick and there was, you know, kind of a mad dash of like, who can support you guys handle this and what can I do and in this case there was actually a medical student who was willing to babysit as many of our medical students have in the past. You know, and, but then there was went on to this discussion about how do you balance childcare and these abrupt situations and how, you know, how individuals kind of mark, you know, you're the backup person in this case you're the backup person in this case and I will tell you from that person that joked we play rock paper scissors in our house. You know, because sometimes that's what it feels like honestly. You know, and we've had many of these even just last week the GI bug hit our house and it was like 1230 there's a kid puking in the bathroom and we are looking each other like, who's got the schedule, you know that that can accommodate staying home with them tomorrow. And I think to acknowledge, you know, that's the reality that plays out in many homes, you know, and we've got a GI bug. We've got strap going around right now like all of these childhood illnesses that are seemingly minor have still really significant effects on their care on the caregivers of these children, but also significant on the workforce and the ability to deliver medical care as intended and even economically. We talked about the effects of caregiving on mental health and I want to take a minute to acknowledge that there's wide variation in the mental health services that are available across institutions. Many institutions have employee assistance programs. Often these are very site specific and differ quite a bit. And in addition, these employee assistance programs can sometimes support childcare and elder care needs or help identify needs but those can also differ very much based on what's happening locally related to the childcare and elder care workforce. I think it's also important to acknowledge that sometimes these services are available institution within institutions but not well advertised or only available to certain groups, or certain ranks of individuals and so thinking about how are we supporting individuals across the lifespan recognizing that individuals at all stages will be caregivers. And so beyond kind of the leaves, you know, in academic institutions a key part of what's expected and what's necessary for promotion and advancement is even things like conference participation and training to network to present. And these things are important and at the same time often require individuals to be away from home, which can be nearly impossible for individuals who have childcare and elder care responsibilities. Professional organizations have come together and actually put together recommendations in terms of what conferences can do. So providing things like childcare, accommodating families and making it possible for families or family members to attend the conference, sharing resources within the local environment where the where the conference is being held, and also helping establish social networks between individuals to think about how to pull together care. Here's an example at a professional organizational level institutions can also provide similar support for dependent care and here at University of Chicago. There is a professional development travel grant that used to only be offered to assistant professors and now has been broadly offered to individuals at all levels that provide support of up to $1000 for childcare or elder care responsibilities in the setting of a faculty member attending a conference and so really a great tool. It's not commonly present across institutions, but a really important way that institutions can support care. And then I, you know, kind of thinking beyond just the individual conference piece. There are, you know, some really unique programs that have come about in the last 10 years. So, Doris Duke, the Doris Duke charitable foundation led some work to create a fund to retain clinical scientists, and their goal was focused specifically on early career researchers, and to support those who were facing family caregiving responsibilities and help support productivity during that time. This fund is is met was meant by the foundation to serve as a small amount of funds for the researcher to use to support not their childcare or their elder care, but support the advancement of the research. I'm thinking about supporting additional effort of the individual so that they have of the faculty members so that they can more broadly do their, you know, commit more time to their research during those vulnerable times, or to fund what they call extra hands. So a coordinator a data analyst a writer, a research assistant that can help do some of the recruitment the data collection the pipetting the animal management etc. But can be really challenging particularly on a day when a child is sick or at if that data collection has to occur in the evenings and things like that. The outcomes to date have shown that pretty small investments by an institution can have a really large return of investment for them. So the doors to foundation in a second iteration of the program actually came together, recognizing the impact of the pandemic on early career researchers came together with multiple other foundations, including the Walter foundation to fund a coven 19 fund to retain scientists and we here at the University of Chicago, we're fortunate to receive one of these grants for the secured program with Dr Olapati and Dr Aurora, and have been able to fund 10 junior faculty researchers to date to provide, most often, you know, extra which is the case that it really has been nationally. Is that about 90% of these funds are used for extra hands so each of these individuals receives, depending on how long they're funded for about $30 to $50,000 to use for over one to two years to support additional staff, or their time to move their research forward. In the process of working with these individuals. We've been, we've had the chance to chat with them about what have you know their experience has been their barriers to challenges what they would like to see, which has been really insightful in terms of thinking about right there's these supports in place and, and how do these supports play out and how have you been impacted. And there's been some, you know, these are just a few of kind of the powerful messages that have been shared. And some other insights I will pull into my recommendations kind of coming forward. No highlighting both the benefits of the pandemic and that they've seen but also challenges that they've encountered in their own environments or with the support that's available. So fixing the system. You know, I think there's, there's quite a few what I've what I've highlighted for you is a variety of, you know, supports that do exist. And then the question becomes like, well that's great isn't that enough. And the reality is it's not. It's not systemic, and they often lack full implementation. I think at the same time caregiving continues to be stigmatized and so there are many opportunities to improve the system. I think we need to recognize that the system was not designed for a workforce that had a significant percentage of individuals who provide caregiving, and that you know we really need to move beyond what has been done in the past people to stop being caregivers. And hopefully over time people there will be more equity in caregiving, but we really need to remove the stigma that exists with with it. There is individuals and groups have shared ideas have had to create more family and caregiver friendly workplaces. I'm going to kind of leverage some of these suggestions and add my recommendations, really using the sociological model to think about it. So how do we fix the system and how do we create that solid foundation that people can stand on so that the wind and the tide doesn't blow them away. So I want to start first at the institutional level in our workplaces. One of the main, you know reasons that that women leave academics. You know, comes from the perception that institutions are not supportive of caregiving of maintaining a family. Promoting that caregiving friendly workforces and workplace is important. I think traditionally institutions have used the one size fits all system. This, you know works here this will work here. We really need to move beyond that because each organization and even each department has different needs for their faculty and their staff which influences experiences. And then using that to both develop adopt and implement policy is important, but we can't stop there we need to evaluate what is that policy doing assess its benefits, but also it's unintended consequences, and then use that information to refine the policy. For example, at Harvard, at one point they enacted a policy that indicated that fathers can take the same amount of leave as mothers after the birth of a child. What's really good to happen that over that time is that it essentially became a leave where faculty members male faculty members wrote books, and so it was essentially perceived to be like, this is when you go and you write a book. Right and so we've created a culture and where there is there's an institutional policy that says you get a you know you get 12 weeks leave. But even within that policy we've created a culture where within a smaller group, there is an expectation that you're using that time away from teaching a class or away from clinical work to be academically productive right and so recognizing these unintended consequences happen and we need to understand those and refine those refine the policies that exist. It's also important to create transparency and clear processes individuals should know about how to do something when to do something what's expected of them, because that can really ease the work the time that's required for something and also streamline the processes that are required. Data suggests that work control is closely linked to career satisfaction and so enabling flexibility can help support that control within the workforce that control within the work environment so everything from the starter and times of a clinic, or enabling opportunities for telehealth or the use of telehealth can be really helpful, even things like, you know, creating more than one time of a meeting. So that individuals can, you know, if you want to create a meeting that has to have, you know, at 7am, make sure that that meeting is also available at 4pm, so that individuals can attend when it's it's convenient for them and acknowledging that 7am is probably not a time when many caregivers can attend. What's also important in an institutional level is that we really need to leave like the medieval times in terms of considerations about, you know, promotion, tenure timelines, and even expectations for call and RV use. It's unreasonable to expect people to squeeze their call into a smaller amount of time or to just add on an additional clinic visit. So, we really should be thinking about how do we adjust the call expectations are there are view expectations for leave and lactation to ensure equity in terms of the service load and really demonstrating a longer investment. I think also, you know, we have very traditional promotion and tenure timelines, but it is a faculty member any less talented if it takes them nine years to do something rather than eight or 10 years to do something rather than eight. And I think that's a tougher reflection because I think that is a larger point for discussion. Thinking beyond our institution it's important that we think about communities and in this case, both local communities, thinking about building robust childcare and older care programs and workforces in the communities, because that can really elevate everybody right it can elevate our staff our trainees and our physicians. We're thinking about creating clear linkages to services that are available. And if we know that, you know, family caregivers often go forth and need to find financial advisors or need to develop wills and living trusts. You know, having those types of resources readily available, having resources available beyond mental health supports within our employee assistance program.  I think also thinking beyond our local community and professional organizations and even, you know, National Institutes of Health, National NSF the National Science Foundation. And how those groups can facilitate participation and attendance and in person meetings. And, and funding that can support that that challenging time that individuals can experience with caregiving. And then also I would say at the national level, the policies and the laws that we adopted the national and the state level. We also have direct influences on our experiences, day to day. And so we need to promote more equity both within the healthcare and in the workforce but also societally. We can leverage our position as institutions and as physicians to recognize those broader implications of caregivers, and can advocate both for informal caregivers and paid caregivers. It's important to recognize that this this work doesn't just occur in one place but really must occur across all the levels. And that there's much that we know from our clinical and our research settings. So using concepts like user centered design, you know what would an individual who has a child. How can we set up a system that's designed to support them as opposed to, you know, here's what I think they might need. Also using concepts from quality improvement to iteratively continue to improve the aspects available and then implementation science to think about not just policies but the unintended effects of policies. I think it's important that you know we not just do things and pat ourselves on the back but we continue to elevate the work that's done. So to wrap up I hope you walk away with understanding that informal or family caregiving is common. I think even having grace for those around you asking them about it supporting them in it is an important part of what we can each as individuals do every day. Family caregiving has largely negative effects on both physical and mental health as well as career outcomes and hence the imperative for systems needed to treat family caregiving as a norm rather than an exception. Action at various levels can help support physicians who are caregivers and it's important for us not to just be idle and not just to be satisfied with what already exists but to really continue to elevate that to support equity in the physician workforce. Thank you. I have a number of excellent questions in the chat and we'll probably answer those then stop and ask the ethics fellows to come forward so I'm one of some that need to lay tear upon who's done work in this area and it's just also on our back are and basically highlighting that the community has been pretty supportive of the lactation culture and the fact is continue to advocate for that. So even if she was talking also responding to your letter of the law versus like the culture and working on both of those things. My next question is from Arlene Ruiz Deloringa and she in dermatology and if you enjoy part of your caregiving role and know for example that there is a short time where your kids are young. When your partners are still alive how can it be reconciled with the timing and road for advancement and promotion, where a slower path, where a slower path may be acceptable. That's a great question I think it gets back to this piece that we have these very like archaic promotion and tenure timelines you must, you must have done this and we have to stop the clock. You know and I think most of us don't walk around feeling that there's a ticking clock, although you know sometimes that is inspired in us. But we don't want to feel that because we want to be able to enjoy the time with our children or with our parents or things like that. And so I do think it really falls on, you know, at kind of the highest levels for universities and academic institutions to think about how have they set up promotion and tenure timelines. And what does that mean for someone who it takes a different pathway because again is is four years versus six years versus eight years versus 10 years. Really a big difference if they've accomplished the metrics.  And so I think these decisions that are made about what what the requirements are for promotion and what the number minimum number of years are or minimum number of years, or you're out. I think can be really limiting for those of us who may want to enjoy that time and return to a more full time schedule down the road. And then Dr Miller asked basically other other countries that we could model after and that we should really adopt their policies. So I start with that could be another hour long talk. I think there's a lot of work internationally that you know better accounts for it. I think a large part and I think the part that's probably best known is just parental leave policies. You know there's many countries that are that allow six months or even a year of really, you know, there's no RVU requirement or productivity or things like that. You know, and so I think there's many, there's many things beyond that and the nitty gradient and I will acknowledge right like our system is not an international system. And so we do have to think about how is it practical, or how it can be adopted but I think even thinking about national policies that can even start to align with some of those things can be a step in the right direction. Yeah, I just really wanted to chime in to say, as a academic grandmother for Anna, because I'm the academic mother for me. This was one of the best things that happened during the pandemic to apply for a Doris Duke clinical scientist award, and for the women who are in this room. And for those who are outside. I think we have to be the change in the system. Right, because otherwise the system is not going to change. And since we're doing this in women's women's month. Since gender equity is really important for global health for health and wellness of society. I really want to say a big shout out for Anna, because it was really a tough time. And I also know that Francis Collins NIH, every funder is trying to make sure that we have gender equity in our health system, especially in academic health because we need more women leaders not less of them. So whether you talk about gender equity racial equity, what you just said is, is really important, we have to change the systems to support women in the workforce because that's the reality. And as we were thinking about encouraging men to be better partners to women, we also said we will fund men, as long as they are providing caregiving and they are caregivers. So I really appreciated your definition of caregiving because we have to be in this together in solidarity together. And thank you for organizing this and there's a lot of work we have to do, but we're going to stay in this institution to fix it, because we can't let the future women who are coming to America school down. So thank you, Anna. All right, so with that we will stop the recording and then ask our fellows to come down to the front and have the informal discussion with Dr. Rollerman. And then thanks to everybody else who came and participated.