Moral Injury in Medicine: Building Bridges Between Leaders and Frontline Teams

Welcome to the AMA Steps Forward Podcast. Here we explore physician-developed solutions to help care teams and their organizations thrive. Empowering physicians, transforming practices. This is AMA Steps Forward. Hello and welcome to this episode in the AMA Steps Forward Podcast series. I'm your host Dr. Heather Farley, Group Vice President of Professional Satisfaction and practice sustainability here at the AMA. This is the third and final podcast episode of our podcast series on moral injury. If you enjoyed these episodes, stay tuned until the end, where we will be sharing details on an upcoming webinar featuring all three of our moral injury speakers. In our first episode, Dr. Wendy Dean offered a frontline clinician's perspective, defining moral injury as a betrayal by a legitimate authority in a high-stake situation that compels clinicians to act against their deeply-held beliefs. She distinguished it from burnout, pointing out that moral injury can cut differently, eroding a clinician's sense of themselves as a good moral patient-centered person. She also noted that leaders aren't immune, a thread that Dr. Jason Lassondrini picked up on in our second episode. Dr. Lassondrini seconded Dr. Dean's interpretation of moral injury and added that he describes it as an accumulated weight of repeated instances of moral distress that sits on clinician's shoulders. He reflected on a particular burden uniquely painful to leaders. The expectation that leaders must implement organizational decisions that are not always aligned with their own values. Leaders often find themselves caught between directives handed down from above and their own deep sense of what is right for their teams and patients. And carrying out those directives even reluctantly takes a cumulative toll. He reminded us that this tension is not a sign of weakness in the leader, but naming it and seeking support is in fact what good leaders do. So that brings us to today's conversation. We're joined by Dr. Catherine Mies to explore what may be one of the most pressing challenges in healthcare culture, healing the trust gap between the frontline workforce and leadership. Thank you so much for joining us today. Welcome. I'm so glad to be with you. Thanks for having me. Before we get started, would you mind telling our listeners a little bit more about yourself and your background? Yes, so I didn't start my career in healthcare. I got here as fast as I could. I actually started working in oil and gas and finance specifically and made a pivot to healthcare and interestingly my beginning of this work and trying to help leaders become the best possible leaders they can be started not in the US healthcare system but in rural Uganda where we were installing solar panels on hospitals and clinics so that they could have reliable electricity to do things like refrigerate vaccines, have a blood bank or have good surgical lighting. And while we were at a particular hospital, what we heard from the surgeons in that environment was really an amazing story of heartbreak of how poorly their outcomes were because they would lose surgical lighting and electricity in the middle of the case and they would often try to finish the surgery with a light from their cell phones. And these were not iPhones, these were like Nokia cell phones with very minimal lighting. And so as you can imagine, outcomes were very poor and there was a lot of imaging, a lot of bleeding and a lot of unnecessary deaths. And so when we went to meet with the administrator of this hospital, what I noticed unfortunately is that over the operating theater there were solar panels and the electricity for those solar panels had been rerouted to the administration building so that the administrator of the hospital could have access to power his computer. And when I walked in for the meeting he was on Facebook. And so it was my first introduction to how harmful poor leadership can be and the degree of human suffering it can cause. And so that made me very, very committed to this idea that if we don't fix the leadership problem then we are going to be completely restricted in our ability to actually make progress. And I think what many of our goals are, which is to alleviate human suffering. And so I committed at that point that I was going to get to the very heart of this thing. I was going to go work in healthcare leadership, I was going to work in administration, I was going to study it, I was going to research it, I was going to teach it, with the ultimate goal of helping leaders keep their people and keep them well so that we can do important and life saving work. Where I've ended up on the other side of that journey 15 years later is that I think most leaders that I encounter want to do the right thing. They want to take great care of their people, they want to make sure that patients are receiving the best possible care. I don't think they want to do a bad job, but I do think they're often things that get in the way of great leadership and getting the outcomes that we want that are not always readily apparent to us. And so the majority of my work is in that space, trying to help leaders see what might be getting in the way of great leadership for themselves, for their teams, for their organizations, and giving them the tools to try to do something about it. Wow, I did not expect that answer, Catherine. What a journey you have had and what a compelling story that began your journey towards this work. So let's dive in. I talked about how last time we spoke to Dr. Lesan Drini about moral injury in leadership. And similarly, your research shows that health care workers with supervisory responsibilities consistently experience higher burnout rates than others. Why do you think that level of leadership carries such a disproportionate burden? I think when you become a leader of others, whether you realize it or not in the moment, you are taking on a tremendous duty to care about the people that you serve, not just your patients, not just meeting your organizational objectives and goals, but caring for the people that depend on you and whose every day lives you affect with your decision making. And that's a heavy burden. I think also what we've seen very consistently in our research is that this is not just a dynamic that we see among physician leaders or people who are supervisory in the non-clinical space. This relationship holds for nursing managers, clinical, non-clinical, almost every role that we could define within a health care setting. We were seeing the same dynamic after a number of controls. And so I think there's that dual weight of responsibility of how do I move the mission forward and do the things that I can test to do. And how do I care for people well in the process? And there are so many examples in a scarce environment where those things feel at odds. Healthcare is by design scarce, right? We know that we're spending an increasing amount of money to provide health care services throughout the United States, margins are getting thin, it's expensive to do business in this space. And so there's just not a lot of extra resource laying around. And so in those environments, balancing our desire to do great work to take great care of our people and to make the best use of the little resource that we have is really exhausting in its overwhelming. I think the other thing that happens in that space is that leaders are often moving from one side of the equation to the other, meaning we go from being us to being one of them. And so often leaders have been in a position of being able to look upward at leadership and say these people are doing these things. These organizational things are happening to me. And when you're an employee, you get to have that story. When you transition into leadership, you no longer get to have that story because you are now part of them. And so I think for a lot of people, there's a challenge in balancing what they know about from being on the front lines and how they've experienced that and also not wanting to be part of the problem. But you get exposure when you become a leader to all of the organizational constraints, all of the environmental factors that go into some of these decisions. I think that can be a tremendous stressor. Katherine, I'm reminded of something that you shared with me maybe a couple of years ago. And it was in a talk that you were giving and you shared the old adage of no margin, no mission. And any more that should not be no margin, no mission, it really should be no people, no margin, no mission. Did I quote you correctly there? You did. I'm very aware of the financial realities of our industry and I'm very aware of the operational realities of our industry. We have to have money to keep the doors open and to be able to pay people their wages and to be able to grow for the future. Unfortunately, we're seeing a huge increase in both labor expense and supply expense. And so just to be able to provide the same amount of care that we're providing right now today often means that organizations have to grow in productivity between nine and 13% year over year. And so sometimes what feels like growth for growth sake or what feels like these organizational initiatives that seem unnecessary sometimes are often very necessary for survival. That said, Heather, in so many industries, what actually makes that money would actually produces the core of the business are things like very expensive equipment in the middle of the ocean, right? An oil rig, for example. And so people are important, but there's a lot of equipment that really is producing the core of the business. In healthcare specifically, the entire business could be summarized in one sentence. It is humans working with humans to heal humans. This idea that we can somehow magically pursue financial and operational performance without taking great care of the humans that make that happen I think is a myth. And so while no margin of admission has been popular in healthcare for a long time, it certainly is based in reality. In 2020, we were canceling electives surgeries, which is the financial lifeblood of most healthcare organizations to prevent the spread of COVID-19. In 2021 and beyond, we were canceling elective surgeries because we couldn't staff that are the pack you. And so without our humans, we have no other margin, we have no other mission. As much as I believe that taking great care of the people doing this work is a moral obligation and that it's the right thing to do, it's also impossible to have a business without it. And so if leaders don't believe in it as the right thing to do, then at least as a business imperative, taking great care of the humans that do this work is absolutely mission critical. So well said, and I think to the point of this podcast, this last, this third podcast in our series, leaders are part of that equation too. They are humans that our systems depend on as well. And again, that's why it is so important for us to have this conversation and to bridge that gap between leadership and the frontline. And so your research describes some unexpected factors that can erode trust between frontline clinicians and administrators, each contributing to each others' distress. How does that cycle typically start and why is it so hard to break? So we wanted to understand what's causing people to consider leaving health care, right? If our ultimate objective is to keep people and keep them well so that they can take great care of patients, what are the factors contributing to that? And interestingly in our research across the entire health care team, physicians, nurses, advanced practice providers, clinical, nonclinical, you name it, what we found is that across all of these groups, the top predictor of turnover intention was burnt out, which I think is probably not a surprise to anyone in this space. But the number two predictor was trust in senior leadership. And so when people had low trust in senior leadership, they were more likely to leave. And that was the number two factor, which explained more than money, it explained more than operational friction, all these other things that we tend to point to when we think about the turnover equation. And so the next logical step from there was to understand what's contributing to trust in senior leadership. Because surely, it's not only one person's behaviors that are causing all of these things. And so what we found is that often what's happening in organizations is what I call the middle management trust gap. And it goes a little something like this. I am in a level of leadership somewhere between the bottom and the top, meaning I'm not a frontline employee, but I'm also not in the C-suite. And I am getting hard questions from my people that I don't really know how to answer. Okay. And these hard questions are things like, why are we building this new building and nurses haven't gotten a raise in three years? Okay. Why are we doing this thing when I don't have the equipment I need to take care of my patients at that side? And so when leaders hear those questions and they don't exactly know how to answer them, what tends to happen is some us versus them communication. And so in order to say face in that moment, because that leader has to work with these people every day, if I don't know how to answer that question, I'm going to say some version of, you know, I asked for your raise, but those evil greedy people upstairs said no. And so when we do that, we get the win in the moment, but it's the ultimate backfire. Because at the end of the day, people want to be very proud of where they work. And health care, I think every health care organization I've been a part of does these little black soft shell jackets where they embroider the logo on the upper left corner. If we all purchase these together, like we would bend the cost curve of health care. So we all do this, right? We get a great volume discount. But we do that because we want people to represent our brand, right? Out in the community, we want them to feel a sense of pride and a sense of ownership. We want people to wear those to the grocery store proudly, not to put them in the donation bin. And I cannot be proud of where I work if I work in an organization that is run by evil greedy people. And so while it feels good to take that win in the moment, when we throw senior leadership or whatever level above us, that level of leadership under the bus, we actually end up doing long term damage to the people that work for us because they might have a great relationship with us as their manager or as their direct leader. But if ultimately they don't trust the people at the top, are decent people with their best interest at heart, they're not going to stick around. And unfortunately, the people with the greatest opportunity to leave and to go somewhere else where they can be proud to work are your highest performers. And so it creates this cycle where we're trying to say face in the moment because we don't know how to answer these hard questions. People trust senior leadership left. They leave us. We have to backfill the positions and it's really a downward spiral. And so one of the things I recommend, particularly for people who are in that middle position, is that it's your responsibility to make sure you're getting answers to those hard questions. And if you are a leader of leaders, it's your responsibility to ask your people what hard questions are you hearing? And so that question alone, what hard questions are you hearing allows people to surface information that they are having trouble answering without outing themselves as being incompetent or not knowing how to answer a question because they're just reflecting back to you. This is what I'm hearing. And so I think there's a huge communication opportunity here for the leaders in the middle to be master storytellers connecting what's happening above and what's happening below, in a way that allows people to understand where their organization is, why they're doing the things that they're doing, and to be able to do that in a way that is authentic, but that is also values aligned in positions that organization well. Katherine, you just dropped like 10 pearls, I love that, and you know, it is really helpful I think for our listeners to understand the unique role that those in between leaders are in and how essential, how they position the storytelling about the leaders above them, how impactful that is for the experience for their teams. And you know, the importance of them as those master storytellers in a way that is authentic and values aligned, but that requires both leaders above them to ask, as you said, what difficult questions are you hearing? And then for, you know, leaders in that for lack of a better word, middle management band to have the courage to ask for clarity to help them answer those questions. And it just reminds me, you know, when we look at data specifically even from our organizational biopsy at the ANA, we see differences in trust for immediate leaders, you know, your immediate supervisor versus senior leadership, and I think some of what you described explains why we see that gap. Well, and Heather, I'll build on that by saying we just came out with a new study, it's been, you know, in peer review forever as they do, that actually could quantify that. And so certainly the senior leaders behaviors matter, right? But interestingly, we found that over 35% of the variance in whether or not people perceived senior leaders to be honest and ethical was actually driven by free behaviors in the middle of the organization, not necessarily senior leader behaviors. And that was the satisfaction with the job performed by the manager above my direct supervisor. Right? So my one ups one up, how well is that person doing? Whether or not my direct supervisor communicates organizational goals, becomes the storyteller that we've just talked about, and whether or not different groups play well together or work well together. Because if my department doesn't get along with your department, I'm going to kind of wonder who up there thought these two leaders were a good idea. And so while that senior behavior matters, how we do those things in the middle also matters quite a lot. In our own research, we found that there are wide variations in trust of senior leadership for people who reported to the same senior leader, which we wouldn't expect to see if it was only senior leader behavior. So knowing how much this matters to people in the retention equation, we all have an opportunity to contribute here. And it's really fascinating. And so we've talked about how moral distress situations in healthcare are pervasive driven by challenges like funding cuts and difficult decision-making and fast-paced environments. And we talked a little bit about how that goes wrong, but how do you have honest conversations about accountability and broken trust without turning it into a blame game? It's a tough one for sure. I think there are two components here for me. One is that I tend to believe that when people understand all of the constraints of a decision or all of the factors that are going into a decision, whether that is organizational factors, macroenvironmental factors, regulatory things coming down the pipeline, they tend to arrive generally at the same logical answer. And so there's a part of that storytelling component, which is helping people get more clarity on what was actually going on around this decision and why was it made. I see so much damage in this space that is sitting in that lack of clarity. So I'll give you a very common example that I see. And it's funny because when I talk to leaders around the country about this, a lot of times they'll say, "Oh my gosh, you shouldn't talk about our organization. It's not even them." Okay, this happens all the time. Scenario is organization gets some funding source, whether it's a big philanthropic gift, whether it's a grant from the state, to build a new institute or build a new building. So they do what we all do, which is a social media campaign. You can do 3D walkthroughs of the building. You know, there's that picture with golden hardhats and shovels that we all do. And a lot of excitement around it. Okay, so there's a stream of storytelling that's happening around that activity. And then on the other hand, we have perhaps an operation. Conversation that sounds a little bit more like this resources are scarce supply cost is going up labor expenses going up We cannot give raises this year or cost of living adjustments and so in the absence of good story telling what people Humans as since makers will do is put those two data points together and we have a story between them that makes sense to them And so often that story is these greedy evil people upstairs only care about building their empire and not supporting the people who Are actually doing the work of patient care now you and I both know that from an accounting perspective you cannot take Money from state funds that are designated for a specific purpose and use them to give people raises You'd have to be very creative with accounting and in my experience creative accounts go to prison It's like never in the job description And so we know that but does your average employee know that or understanding the account accounting principles at play probably not And I think the challenging thing Heather is that the damage happens from the perception that people have It's the perception that drives behavior. It's the perception that creates the sense of betrayal And so sometimes our opportunity as leaders is to help clarify what are the actual conditions surrounding this situation so that people are not taking on unnecessary feelings of betrayal Now that's kind of one set of decision-making the other set of decision-making is that sometimes Leadership or the organization is going to make a decision. You do not agree with right and you might see the harm of that decision in a way That leadership does not and then you're stuck in the middle trying to figure out. Okay. How do I not throw leadership under the bus? How do I not throw corporate under the bus? But how do I also make sure that I'm Making it known that this is not reflective of my beliefs. I think we've all been there I think we've all been there where you're like, okay, I don't want to throw them under the bus But I hardly dissent against this decision and I think in that one There are a couple considerations that come into play one Do you fully understand the story behind the decision-making if not get very clear on that first before assuming that you would have not made the same choice? Two, sometimes I believe that it is appropriate that when higher levels of leadership make a decision that is at odds with Your values at odds with probably what you think might have needed to happen for the organization that you invite them to Experience the effect of that decision and so while you're going to have to communicate as a leader I don't think it's a bad thing sometimes to say hey, I'm having a little difficulty Explaining this decision to my people in a way that aligns with the values of the organization that they can internalize and understand I would love to invite you to our next department meeting so that you can help Explain this decision so that you can give them a little context behind it I think they would really like to hear from you because what happens in organizations is nobody wants to look like they can't do a good job So they filter how well things are going a little bit on the way up and sometimes by the time things get to very senior leadership Everything's fine. And so by opening that communication pipeline a little bit We also give senior leaders an opportunity to be more in touch with the organization and to identify for themselves Where do they need to be communicating better so that people can adopt their decision-making? Catherine again, so many pearls Thank you. You know speaking of Controversy, I'm gonna ask about another component of your research That has raised this fascinating tension around generational communication styles and the balance between directness and clarity and Support for your teams So how do you think organizations should navigate some of the new communication expectations Without excusing genuinely bad behavior or dismissing real concerns Man Heather, I'm hearing about this all the time where people are saying okay You know, I've got these younger generations in the workforce. I'm just telling them what's going on And they're perceiving it as microaggression. They're perceiving it as hostility I'm not communicating any differently than I have my whole career What is going on in this conversation? And I think particularly, you know, we're starting to see a greater influx of Gen Z in particular into the physician workforce because they are finally making their way out of training and So people are experiencing really different communication dynamics here A couple things that I think are going into this one is that there are much lower expectations for how hierarchy plays into a conversation or Relationship among younger generations in the workforce meaning the fact that you are the senior chair Most research ties publication person in the in the department in prior Eras might have commanded immediate respect and that respect would be shown in a sense of difference now I think we're in a position where most people say okay, that's good for you That's great. That doesn't automatically mean that you're better than me And so this idea the respect for authority. I think is very different and it's just a change, right? And it's unpleasant and it's uncomfortable That said I also think that there's a little bit of a recognition particularly for younger generations where they say hey You have expertise in this certain area, but I'm a digital native I have more expertise perhaps in these other areas, and so they're seeing themselves More as peers or collaborators relative to senior person and I am here to learn from you So this is new and I think it's uncomfortable for a lot of us The other thing I would say is that directness of communication Saying things in a very manner of fact manner sometimes by younger generations is perceived as hostility when that is not at all the attention But we also have to remember that we're dealing with a generation that's been part of their time in high school and college and medical school Home alone for two years shuffling around wearing their Thanksgiving pants talking to themselves, okay? Things got weird and so a lot of our communication norms with each other Sort of disappeared, and we haven't really gone through the process of reestablishing what face-to-face or in-person or real-time communication looks like what's In-bounds and what's out of bounds and so for people who didn't have as much practice with that It's not surprising that they're experiencing it in a different way or having a different skill set around conflict and communication for example Relative to prior generations. So if you'd like either I can give you a couple examples that I've seen particularly on the physician side Hathor and I would love to hear some of those examples Okay, so I was working with an organization and They had an issue with a resident that reported a microaggression to HR Because a patient did not pronounce their last name correctly And this patient was from a very rural low-income environment and likely had some difficulty with their multi-syllabic last name So to feel like patients need to Correctly pronounce your last name or it's a hostile work environment is not a realistic expectation And so there's a huge expectation setting component to this as well So while I think we need to you know legitimately evaluate our communication patterns and say hey Do we have to be brutally honest or can we just be honest like maybe we don't need the brutally part? I do also think there's a huge component of expectation setting of What is reasonable for expectations of workplace communication and what's not reasonable? So I like to call these sailing rules. I love to sail with my kids and There are a lot of ways on the sailboat that they can die, right? Particularly if we hit some unexpected wind things change very quickly I need to know that immediately my kids are going to do whatever I say And that command and control style of communication is a little bit different than how we typically communicate and so I let them know in advance Hey, sailing rules we are getting on the sailboat, which means I'm going to yell at you and bark orders at you And I'm yelling because I want to make sure that you hear me because the wind is loud And I need you to immediately do what I say and not ask me any questions and then we'll talk about it later Because this is how I'm going to keep you safe and protect you in this environment And so they know that it's not personal. This is just sailing rules And I think sometimes we have to do a better job narrating that communication Two different generations in the workforce, particularly younger people who are coming up through their training journey or just starting in this place So it might look something like saying Hey, when I'm in the operating room and I don't know if we're I'm going to be able to save this patient and it is this patient is crashing In that moment, I'm going to dedicate all of my time and energy and space into saving that patient Which means I'm going to spend zero energy thinking about how to soften my communication to the people in the room So I'm going to do my best to maintain my composure But when I get stressed and I'm in fear that I'm going to lose my patient all I'm going to focus on is that And it's not disrespect. It's not me not appreciating your expertise Let's debrief afterwards But I need you to know that it is not personal right so we can get ahead of some of this in setting expectations for how we might communicate in different environments That I think then take some of the emotion out of that experience for people Yeah, that example just really resonated for me as an you know someone with an emergency medicine background We all knew that when we are in some of these high-stakes environments and situations that we are going to communicate with one another very differently Then we will when we have time and the luxury of Soffiting some of our communication styles, but I really like that recommendation of getting ahead of that and Of course, there are still lots of gray area in there, but that at least helps a little bit. So again a really helpful Perl Katherine, thank you. As we're starting to wind down our time together in this conversation for healthcare leaders who are listening, who want to start building or rebuilding trust with their teams. What's one actionable thing you tell them to do differently tomorrow? So I'm going to give one for rebuilding and one for building. So we'll start with building trust. One of the biggest misses I see in the trust equation for leaders is not being very clear about our expectations with people. And so if you don't tell me what you expect of me, whether it's at work, whether it's how I dress, whether it's how I communicate, whether it's my deliverable or how you want this project done, and I mess up, I'm going to feel like you set me up to fail. And so sometimes in our desire to give people autonomy and agency and independence and no one explained it to me when I was coming up, we don't make our expectations really clear. And then we hold people accountable to a result that we never fully defined in the first place. And so I think making your expectations crystal clear, which might mean, particularly with younger generations backing up a few steps from where those instructions started for you is a really missed opportunity for building trust. So that's one thing I would say on the building piece of that equation. On the repair part of the equation, I think we have to get really good at apologizing and forgiveness as core leadership competencies. And that is not something that we are taught in business school. It is not something that we are typically taught in the work environment or in leadership training, but it is so critical. The science is actually with us on this one. And much of this research is actually done in the healthcare environment that we know that forgiveness improves job satisfaction, productivity, innovation, performance, the physical and mental health of both the forgiver and the forgiven. And it restores our sense of humanity. Often we are moving so quickly that we think, okay, if I just move on, people will kind of forget about this mistake and we will just keep going. And I can tell you after reading thousands and thousands of pages of employee engagement comments, nobody is forgetting. Healthcare workers have memories like elephants. You know, there is that thing from 2014 and it is hanging on like a barnacle. And so the more we can routineize this process of owning our mistakes, apologizing and forgiveness, the more we are going to develop what I call a resin culture. Many trees release sap or resin when the bark breaks and it is an effort to sort of heal or repair that bark so that the trees stay strong. But there are some trees that before the bark breaks, when there is just the slightest hint of a stressor or a tiny fissure, it will release that resin so that the bark never breaks in the first place. And I think creating those resin cultures by doing this frequently and modeling this for our teams is absolutely critical as we think about how we rebuild trust. I love that analogy. And I am going to flip that question and ask you, what about frontline physicians and care teams? How should they think about their role in restoring or rebuilding trust with their leaders? Yeah, so it is a two sided equation, right? We can't only have one party in this two party experience doing the work. I think there is a component of leadership absolutely that is leader behavior that is on the shoulders of the leader, but there is also an element of followership or being a good follower. There are ways in which I think if we are being really honest with ourselves, we can make our leaders miserable by not exhibiting humility, by not being thoughtful with our questions, by not choosing what battles we are going to fight, like if everything is a fight, you know, you have probably overdone your quota. And so I think there is a huge opportunity for people who are trying to also build that relationship with their own leaders so that they can do their job well. In taking responsibility for your own piece of that equation, one of the things I see so often, Heather, is that there are people who work in health care, particularly in the clinical space that often feel like health care is happening to me. The organization is happening to me. I have lost all sense of agency. And I think if we can make a mindset shift, there are actually a lot of things that we can do from anywhere we sit in the organization to make that a better place for ourselves to work, for our patients to experience care and for the people that we work alongside. You know, we have to own some of that responsibility for the culture and the organization that we're creating from anywhere we sit, not just a leadership role. I think that is a great place for us to land. Health care is such a difficult environment. It is uniquely challenging, but also uniquely rewarding. And how we navigate some of those challenges together in this rapidly, rapidly changing environment is really everyone's responsibility, both our frontline clinicians and care teams and our leaders in recognizing that we are all human. And how do we work through this together to restore humanity to health care. And you know, giving each other a little bit of latitude, yet also recognizing when we need to own the ruptures that we have created so that we can restore trust with those that we work with to do this difficult and rewarding work together. I'm going to ask you, Catherine, any other pearls of wisdom that you'd like to share before we close? I think the biggest thing I would say is never underestimate the difference that you make. You'll never know the impact that you have, but you have so much power from anywhere you sit in the organization to be a positive influence on the people around you. And so just don't just count it. Well, thank you so much, Catherine. I really appreciate you sharing your research and your experience and your expertise with us. So for our listeners, our guest today has been Dr. Catherine Mies. Please join us on October 6th for a webinar showcasing all of our guests from this moral injury series. Dr. Wendy Dean, Dr. Jason LaSondrini, and Dr. Catherine Mies. You can head over to stepsforward.org for more information on how to register. And finally, please check out the episode description to explore the resources associated with this episode. And until next time, stay well. Thanks for listening to the AMA Steps Forward podcast. For more episodes, resources, and CME opportunities, visit stepsforward.org.