Hello, I'm so honored to be able to present the Cindy Johns Memorial Lecture today. I have no disclosures of relevance to this talk, but this seashell is to remind many people about Cindy. Although she was born in Michigan and was trained in Michigan, she spent much of her life in Florida, and close to the end of her life, she brought beautiful shells that she had collected to many of us at meetings that she attended and gave us seashells to take home. So you'll see seashells scattered through this talk as a reminder of Cindy. My goals and objectives are that after hearing this, you should be able to list three ways that Cindy's skills and preparation helped her to develop her career and allowed her to serve as a visionary leader, both as a laboratory professional and ASCP volunteer. Then I'd like you to be able to describe the Russian doll model of altruism, outline the trilogy of hope as defined by Snyder, and then hopefully engage in self-reflection to identify your own skills and knowledge that can help enhance your effectiveness in participating effectively on teams and in developing effective goals and pathways. So Cindy was an amazing person. Here are some pictures of just a few of her activities in ASCP. Quiet time after in-between meetings, looking at scrapbooks, signing the year, celebration of 80 years of the Board of Registry before it became the Board of Certification. And she was truly an extraordinary ASCP volunteer over her career, and this is just a few of her activities. She served as a volunteer for the Board of Certification. She served on the ASCP Board of Directors. She served on the Commission for Continuing Professional Development, Nominations Committee, the Pathology Informatics Committee, the Task Force on Transition. She was a BOC International Ambassador, and she was the first ASCP Patient Champion. I worked really closely with Cindy on the Commission for Continuing Professional Development and also on the Board of Directors. She was also a passionate, excellent, and dedicated educator, and in fact, she started teaching workshops for ASCP shortly after she started her career as a laboratory professional. She led workshops and teleconferences. She also published papers and presented posters on problem-solving in the COAG Laboratory, hemostasis review and update, laboratory evaluation of anemia, evaluation of lymphoproliferative disorders, a talk on the nontraditional roles of a laboratory professional, and on link codings. And she, at her very last presence at an ASCP meeting, was doing a link code workshop with Pam Bamming. Now, it might seem contradictory that I would think about wellness with a picture of Cindy shortly before she entered hospice at the end of her life with breast cancer. But I started working on a three-part, which is now a four-part course on wellness, and I'm adding this as another course on wellness, if you will. And in preparing for the course, I and the other faculty found this beautiful diagram about the eight different elements or dimensions of wellness. And if we think about Cindy, aside from physical wellness, she had robust wellness in every one of these areas. She had purpose in her life. She was actively involved in satisfying work and play. She had joyful relationships. Her body wasn't healthy, but the environment in which she lived and worked was. And she was happy. And I think you can look at this picture and see her radiance near the end of her life. This was at the annual meeting in 2017. So thinking about how difficult the last two years have been for so many of us, if Cindy were to send us a message in a bottle that landed on a beach with the beautiful shells she collected, what would Cindy say to us? Well, first of all, she was a laboratory professional. She was precise, analytical, and a shrewd observer. So I think she would tell us, observe and analyze, map and classify correctly. She was an expert in LOINC, which is Logical Observation Identifiers, Names, and Codes, which is used in electronic quality measures in communicating between lab tests and the electronic health record. In the laboratory, this classification system helps to identify different lab tests and orders, can be mapped and billing, and is important for communication to allow results to get to patients. So she thought very deeply about processes and communication centered on patients. She would say, observe and examine all aspects. So here's the same shell turned in two different directions. And the shell on the prior slide was the same shell as well. She also would say, as you're observing and analyzing, do so with empathy. She combined passion and kindness with her logical approach. She was passionate about communicating lab results and systematic improvements in quality of care. She was passionate about patients having access to clear, understandable results. She was the first ASCP patient champion. She felt very much that the lab serves the patient, and we need to be in partnership with our patients. And notably, she had lived a long time with metastatic breast cancer, and she also was a widow. Her husband had died of cancer. She knew intimately the importance of lab results for patient outcomes. She served, as I mentioned before, on the ASCP informatics committee. And while she was on the board, that is the time that we started discussions about what led to be the National Pathology Quality Registry. She was passionate about finding ways for laboratory results to be visibly important and to show the value of what we do for the patients. She was a visionary leader. She recognized that the future of our very profession is linked to the visibility of the lab as being central to patient care, and that the visibility of laboratory professionals and the laboratories is linked to showing our value, the value that our results and diagnoses give to the patients and to health systems. And she was passionate about using metrics to gauge continuous quality improvement and progress. So I also think knowing all of this and knowing Cindy, she would say, if you're burned out and tired, it's not your fault. Chronic unremitting stress is trauma. She would tell us, acknowledge the impact of this trauma on your personal health, workplaces and communities. Pathologists and laboratory professionals, I don't have to tell you, have spent hours of overwork to get testing up and running, dealing with supply chain issues. And initially, we also had tremendous gut punches that our testing wasn't reaching vulnerable populations who are still dying disproportionately from the pandemic. There's been overloading of forensic pathologists and furloughs and even some laboratory closures because elective procedures fell off in such great quantity. This slide is from a new program called Equity Matters, which LaTanya Norwood and I are participating in as the ASCP team. And this slide is about stress, and I thought it was very helpful that stress actually exists on a continuum. Mild stress and even moderate stress is important for learning and for developing and growing. But when stress becomes chronic and unremitting, it becomes toxic, and that's actually traumatic for our bodies. So manageable stressors build resilience. Experiencing and overcoming stress is critical to normal healthy development, but chronic unremitting stress can overwhelm our coping mechanisms. So consequently, I'm certain that Cindy would be a leader in trauma-informed leadership. Recognizing that every person watching this has faced chronic unremitting stress over the last few years, we are all traumatized. And the six principles of trauma-informed care are to provide safety for ourselves and our coworkers and our family, to develop systems of trustworthiness and transparency, to have peer support and mutual self-help, to collaborate and to find mutual solutions. The voice and choice is very important, and we need to recognize cultural, historical, and gender issues. Now Cindy exemplified all of these things in ASCP and in other volunteer activities. She wanted to empower the patient and the laboratory professionals. She wanted and she built relationships of trust, mutual support, collaboration, and safety. She followed all of these principles. So trauma-informed leaders realize the effects of trauma and chronic stress on ourselves, on the organizations in which we work, on the communities in which we live and with whom we interact. We recognize historical, cultural, and gender expression issues and try to be respectful and inclusive. We create plans for recovery for ourselves and others. We recognize the basic signs and symptoms of trauma in ourselves and others, and we respond appropriately with safety, confidentiality, peer support, collaboration, mutuality, empowerment, voice, and choice. And we must revise harmful policies, procedures, and practices, and we need to resist and actively avoid re-traumatization. So what about our profession, our stress and burnout? Well, Cindy would say, analyze and observe rigorously from all directions and then classify correctly. So she would scan the speech, looking at the whole beach before focusing down. Identify and map the structures, processes, expectations, and limitations in our workplaces that increase our stress or contribute to trauma. Identify those factors over which you have control or influence. Identify potential allies, resources, and any person or groups facing similar challenges. And be alert to ways that you might change your routine or approach to improve your responses. Now again, Cindy took concerns like this to ASCP. She was involved with the governmental advocacy roles. She worked very hard for visibility and increased power for laboratory professionals in the laboratory. So part of potential allies, finding those allies, can be facilitated by membership in organizations that share your goals and values. And ASCP being patient-centric was really Cindy's home. Another thing we need to do is analyze. Is it personal? Burnout can result from working very hard only to realize that we are rowing in the wrong direction with the wrong goals or objectives or we're rowing in the wrong boat. We have insufficient resources, dysfunctional organizations, and in those settings, no matter how hard we row, we cannot get where we hope to go. So it's not your fault. However, you can work with others to try to change the direction, change the goals and purpose, and get the resources that you need. This is a slide I had in my talk last year on mentoring, but I always need to go over this with people. If you were involved, if you were a general of an army and you were engaged in a battle that was not going well for you, what's the difference between retreat and withdrawal? If you retreat, you're forced back. You have lost the initiative. You can't continue forward. It's a strategic failure. It's a partial defeat. You've exhausted your resources and you're demoralized. But strategic withdrawal is very different. You have retained the initiative. That's a deliberate choice to pull back, to regroup, to pause, to rethink your strategy, to pause for reinforcement, refueling. And that is the choice where you retain hope and optimism for a different approach. Again, when you ally with others in an organization like ASCP, you have the opportunity to brainstorm, to find other people who share similar problems and map different strategies with them, and you get fresh air. You don't feel alone. So Cindy would say, look really carefully. Is this personal battles you're facing? Is this systemic? Is it local? Observe and analyze rigorously, and then classify correctly. And people who know me know that I meditate, I exercise, I try to sleep well every single day, and that really helps. These solutions, these personal solutions, truly do enhance my life. But I faced COVID. It's been very traumatic for me or everyone else. So these personal solutions can only go so far. And when the sources of stress are systemic, are located in the workplace, we need additional strategies, and we need allies. We need to engage all members in order to create effective solutions. And as Dr. Carla Ellis said in her talk, wonderful talk on wellness, be present with empathy without losing focus. Observe, but try not to absorb the pain and suffering of others. Witness that, be loving, but don't absorb it. So what advice would Cindy give us? I think she would say, we're in a terrible storm right now, but you can often find the most beautiful shells after a storm or in between storms. And I also know Cindy would have, she did practice the serenity prayer. God grant me the serenity to accept the things I cannot change, the courage to change the things that I can, and the wisdom to know the difference. And here's Cindy at her last public presentation at the ACP meeting in 2017 when she received the first patient champion award. And as I said, she entered hospice shortly after this. When people told Cindy how courageous we found her, she would say, I'm not a saint. I'm an ordinary person. I do the things that I know are right and that I need to do. Even though she was fighting cancer, she embodied empowerment and not passivity. Through her core values, her loyalty to patients, to her fellow professionals, she was a lifelong volunteer and an advocate to improve patient care by improving working conditions, tools, and resources of laboratory professionals. And that was with her work around ASCP certification, education, quality assurance, and global engagement. So what values did Cindy exemplify? And finally getting to the values I had in the title of my talk, but this is what Cindy to me exemplified hope and altruism. So what is altruism? Well, there's actually evolutionary evidence that altruism is an ancient innate behavior of all animals because it allows, when we have an empathic immediate response to others, we can then have quick automatic responses to danger, not requiring thought time to respond. Humans and other animals display rapid responses to distress signals of our young and others in our group. And this emotional connectedness actually has neural and physiological correlates with brain changes on CT PET scans and changes in skin temperature. This is the Russian doll concept of altruism that talks about perception action mechanism. And if we look at the central gray doll at the center of the diagram, that is the most reflexive, basic form of empathy altruism reflex. So this involves emotional contagion that you see when, for instance, one bird is startled and the entire flock takes off and motor mimicry like the monkey, see monkey do, or if a monkey scratches his face, another monkey will then scratch his face. As we become more able to quell reflexive behavior and move into increased self other awareness or distinction, we go to more advanced forms of empathy, such as coordinating and sharing our goals with others, having a sympathetic concern where we can console others without mimicking them. And at the highest level, we are able to have perspective where we have less blending with the emotions of another, and we can make cognitive assessments. We can make judgments rather than engaging in automatic behaviors. So this is the Russian doll model of empathy and altruism. And altruism is powerful. In a study that summarized a number, in an article that summarizes a number of studies, after individuals performed altruistic actions, there was significant reduction of brain activity in the dorsal anterior cingulate cortex and bilateral insula and response to painful stimuli. And there was reduced pain induced activation in the right insula, which was mediated by the neural activity in the ventral medial prefrontal cortex, that area of the brain, when that area of the brain is activated, that was positively correlated with experience of meaningfulness from altruistic behavior. So there are definitely brain changes involved here. And in another study, cancer patients who were given a choice to either do self-care behaviors or behaviors to help take care of other patients, those who helped other patients had significantly decreased experiences of pain over time compared to controls, who are the controls. As I said, we're just involved in self-care behaviors. So the reality is that joy, happiness, and wellbeing are relational. And they're discovered when we lose ourselves in a process, especially one where we're helping others. They're associated with growth rather than accumulation of stuff. And they involve exploration, which involves working with others to solve problems. Pathology and laboratory medicine are patient-centered teamwork, constantly changing and explorational and oriented toward helping others. Now, altruistic engagement and personal wellness. There are a lot of studies that document that regular volunteering and engagement increase our wellness. There are positive effects on physical wellbeing and long-term health. This is correlated with increased subjective wellbeing and volunteering builds connections with other altruistic and giving individuals while fostering engagement around common goals and values. It's good for us, but it's good for others. And we get a lot of personal wellness benefits from helping others. So what about hope? There's actually a science of hope. Hope is a positive motivational state based on interactively derived sense of agency or goal-directed energy, pathways, or planning to meet goals. This is a really nice paper by Snyder, who was one of the pioneers of hope theory and it's hope theory rainbows in the mind. And Snyder talks about a trilogy of concepts. One must have goals. One must be able to generate pathways and one must have agency. So please notice that hope isn't something we have. Hope is a verb. There is a discipline and a science of how to be hopeful. So in hope theory, there are two types of goals. There's a positive goal outcome. So we're trying to reach a particular goal for the first time. There's a sustaining of a present goal outcome, but there's increasing the outcomes of something that's already started. And there are also negative goal outcomes. We're trying to prevent something from happening or prevent or delay something from happening. Pathways are central. A high hope person can develop a plausible route to success with confidence in the plan and is good at generating alternatives, plan A, plan B, plan C. High hope people are flexible, especially when they face obstacles to meeting a particular goal or pathway. Low hope people formulate tentative pathways with the resulting routes, often poorly articulated. They are unlikely to be able to generate alternate routes and they're inflexible and easily discouraged. So this is important information for mentoring. We can help people learn how to make goals, learn how to think about pathways, learn how to find resources for agency. Hope is a discipline that can be taught. And this is a lovely paper about using choice-based reality therapy to strengthen hope in women who are in recovery, incarcerated after drug offense convictions. So this study included incarcerated women in Taiwan who had been convicted of drug offenses. They were randomized to two groups of 20 each. The control group had no intervention, but the study group received hope-based group therapy for substance abuse. And the hope-based treatment focused on Schneider's concepts to help people develop goals, pathways, and agency in 16 sessions. In the hope-based group, the participants had increased problem-solving skills to develop positive pathways. They were increasingly able to set and pursue goals. They had higher energy to pursue their goals, more optimism, and they had an increased ability to generate alternate pathways if the way that they started was not working. And the steps that the authors took involved stage one, helping people learn how to set goals based on needs and wants. Stage two is helping people get enough energy and resources through thinking about the actions they needed to take, thinking about the way they thought about themselves and their own physiology, their reactions to life events. And they use simple questions. What are you doing? Where are you going? What do you want to do in your life and in recovery? List the abilities you have. Who are the friends you have? How will you live? Where could you look for jobs? Helping people brainstorm. Stage three is controlling energy through action planning, building a workable pathway, finding confidence to take actions, including stress management, coping skills, learning self-assertiveness if necessary. And the important thing is that hope equals pathway plus agency. This is another paper on the science of hope in Lancet Oncology that emphasized that hope and accomplishment of goals mutually reinforce each other. And there is a connection between hope and health promoting behaviors patients with advanced colorectal cancer who exercise why they have cancer have longer progression, free survivals. Now Cindy had breast cancer for many, many years and she was an avid jogger until very close to the end of her life. And I have always thought that that might well have contributed to the way that she could live as long as she did with advanced cancer. Oncologists are now looking at trials to see if interventions to increase hope could help decrease perceptions of chronic pain. And there is a psycho neuro immunological basis of hope stress induced stress, increased catecholamine levels can decrease the effectiveness of chemotherapy drugs. In contrast, social wellbeing is associated with a lower pro-metastatic gene expression profile on leukocytes. So there is emerging evidence that training and helping people learn hope can be helpful. So in summary, Cindy was truly an exemplar of altruism and hope. Here she is with one of her dear friends, Walter Oliveira, with whom she served both on the board of directors and also on the commission for continuing professional development and Dr. Marsha Kinney, who was our president elect and a hematologist like Cindy and worked with Cindy on the board of certification and then on the board. And as I close, I would also like to remind you of the four part ASCP courses on wellness, sustaining health and wellness in a crazy world. We hope that you'll get a chance to tap into these presentations, either live or virtually. And finally, I would like to acknowledge with deepest gratitude, the joy and blessing of having Cindy in my life. She continues to inspire me every day. And I would also like to thank the faculty who worked with me on the wellness course, Dana Baker, Dr. Carla Ellis, Dr. Darryl Elsie, Dr. Nicole Jackson, Dr. Lil T. Mulder, who all increased my understanding and appreciation of wellness. And I'd like to have a particular thanks to Dr. Nicole Jackson and our discussions of wellness in the community. She's the one who led me to think about the importance of altruism and hope as key components of wellness. So I thank you all very much.

Cindy Johns

ASCP

altruism

hope

laboratory professional

empathy

healthcare