“We Take Care of Women… But Who Takes Care of Women Doctors?”

Heat. Heat. [music] [music] >> [music] [music] >> Heat. Heat. [music] Heat. Heat. >> [music] [music] >> Good afternoon everyone and a very warm welcome to today's webinar webinar titled we take care of women but who takes care of women doctors. On behalf of the Wonka Working Party on Women and Family Medicine, thank you for joining us for this important and timely con uh conversation. As family doctors, we are deeply committed to caring for women across all stages of life. Yet in doing so, we often overlook a crucial question. Who is caring for the women doctors themselves? Behind the consultations, long hours, and emotional labor, many women doctors navigate significant challenges, balancing professional responsibilities with personal roles while also managing their own physical, mental, and reproductive health. Too often, these struggles remain unseen, unspoken, and under addressed. Before we begin, just a few housekeeping reminders. All participants will be muted throughout the session to ensure a smooth flow of the webinar. Please feel free to type your questions in the chat box and we will address them during the Q&A segment at the end. We will also appreciate if you could complete the feedback form at the end of the session as this will be required for your ecertificates. We are fortunate today to have a panel of experienced speaker from various countries. each bringing valuable perspective and expertise to this discussion. I'm confident that their insight will enrich our understanding and inspire meaningful change. Without further ado, let us begin. It is my pleasure to introduce our first speaker, Dr. Jonah Chrisosttomo. Dr. Jonah Chrisosttomu is a family and community medicine specialist and diplomat of the Philippine Academy of Family Physicians ranking top three in the National Specialty Board Examinations. She obtained her doctor of medicine degree from the University of Philippines College of Medicine as an oblation scholar under the integrated liberal art and medicine program and completed a master in public health with a specialization in health system and development. Her career bridges clinical care, public health leadership and community based uh health systems. She has served as medical officer at the department of family and community medicine of the Philippine General Hospital and as a municipal health officer in Bhutan where she led the delivery and management of local health services. During residency, she was recognized as an outstanding resident while navigating pregnancy and breastfeeding, an experience that shaped her advocacy for the health, sustainability, and well-being of women physician. Currently, Dr. Chrisostomo practices comprehensive family medicine while serving as a woman's health advocate and health communicator, advancing conversations on reproductive and hormonal health, physician well-being, and sustainable medical practice. So, I will pass the stage to you, Dr. Jonah. Good day everyone and thank you for the opportunity to speak. I am Dr. Jonaman Dr. Sosumo a board certified family and community medicine specialist from the Philippines and my topic today is reproductive and hormonal health risks in women doctors across the Asia-Pacific region. We are seeing a rapid increase in women entering medicine. But alongside progress, there are important health challenges that remain underrecognized and often unsupported. So today I will be discussing how reproductive and hormonal health intersects with medical careers and why this matters not just for women but for sustainable health care systems. Women doctors now make up a significant and growing proportion of the workforce across many Asia-Pacific countries. At the same time, the most demanding years of medical training and early career development overlap almost exactly with reproductive years. Women are also expected to take on primary caregiving roles at home. So what we see is a triple burden. professional expectations, biological realities and social expectations. When women are not supported, the impact goes beyond the individual. It affects retention, career progression, mental health, gender equity, and ultimately patient care. I will briefly walk through five key areas. menstrual health, delayed childbearing and the career fertility conflict, pregnancy and breastfeeding in training, and finally menopause. These stages span the entire career life cycle of a woman family medicine doctor. From the initial steps of medical education to the culmination of a fulfilling career, each phase presents unique challenges and opportunities. By addressing these challenges at each stage proactively, we can support a sustainable workforce and ensure that the quality of care remains uncompromised. Let's begin with menstrual health. Let me ask you honestly, how many of us have seen patients while managing menstrual pain ourselves? ACOG estimates up to 90% of women experience menstrual symptoms at some point. Conditions like dysmenorhea, heavy menstrual bleeding and premenstrual syndromes affect the majority of reproductive aged women. But in medicine, there is a strong culture of endurance. Many women doctors continue working through pain, fatigue, often normalizing discomfort. This leads to what we call presentism. being physically present at work but functioning below optimal capacity. This can result to diminished productivity, increased mistakes at work, and potential health issues. And yet, this is rarely acknowledged as a legitimate workplace issue. Across many Asia-Pacific settings, ministration still remains a sensitive or even a taboo topic. This makes it difficult for woman doctors to speak openly, request adjustments at work or seek support openly. We treat menstrual problems in our patients yet paradoxically ignore them in ourselves. As a result, symptoms are minimized or self-managed. But over time, untreated fatigue or pain contribute to decreased productivity, increased risk of burnout, and reduced well-being. Menstrual health is a hidden burden because it is rarely visible but widely experienced by many women. By recognizing and addressing these issues, healthc care providers can better manage their own health, ultimately enhancing their ability to care for patients effectively and fostering a more supportive environment. Moving forward in the reproductive life course, let's discuss fertility. When we talk about reproductive health among women doctors, one of the most consistent findings across countries is that physicians are having children later than ever before. Medical training overlaps almost perfectly with a woman's peak reproductive years. Residency, fellowship, board certification, and early career occur at exactly the same time when natural fertility is at the highest. Studies consistently show that many female physicians intentionally delay childbearing because of medical training and career demands. Delayed childbearing among physicians has measurable fertility outcomes. Studies show that physicians experience higher rates of infertility and higher use of assisted reproductive technologies or ARTS compared with the general population. Many report pregnancy loss or difficulty conceiving after training when they finally feel professionally quote unquote allowed to try. A national study published in JAMAMA network open revealed that nearly one in four women doctors experienced infertility with many reporting that long training pathways and career pressures influence the timing of pregnancy. So women physicians know and understand that fertility declines with age. Yet despite this knowledge, why do many physicians still delay pregnancy? Well, this delay is rarely a purely personal choice. It is largely shaped by the structure of medical education itself. We train long and work unpredictable hours. And many young doctors perceive pregnancy during training as professionally risky. Whether that risk is real or simply culturally reinforced. This refers to what we call as the career fertility conflict. The intense nature of our profession means that many women medical professionals find themselves at the crossroads where the pressures of career advancement and the demands of medical training and practice clash with their natural fertility window. Nearly twothirds of women physicians report modifying career aspirations and delaying fellowships, reducing academic ambitions simply to fit biological timelines into rigid training systems. One striking finding across studies is this. Physicians generally have high fertility knowledge yet the delay persists because of number one workplace culture. Number two is limited training flexibility, lack of parental support policies, inadequate support from peers and leaders, and fear of career penalty. So, navigating the balance between personal and professional aspirations can indeed be challenging. So, solutions must also happen at multiple levels. At the individual level, we need earlier fertility awareness during training years. Proactive discussions about fertility preservation, reproductive timelines and personal priorities should be normalized at the support system level. Mentorship is indeed powerful. Seeing physician mothers who successfully integrate career and family helps younger doctors envision sustainable paths. Peer support groups can also play a crucial role in helping female doctors navigate complex decisions. Shared caregiving and family support can also reduce the burden placed solely on women. Finally, real change requires community and policy action, including paid parental leave, flexible residency pathways, and institutional cultures that recognize parenting as compatible with professional excellence. Organizations must cultivate work life balance and provide ways for career advancement without penalizing those who choose to prioritize family at certain life stages. Open discussions and supportive workplace policies can also help alleviate pressures and encourage more holistic approach to career and family life. The goal is simple. Women physicians should not have to choose between becoming excellent doctors and becoming mothers. So medicine asks women to delay motherhood. But it rarely adapts when motherhood arrives. Pregnancy still often occurs during training and residency which is the one of the most demanding periods of a physician's life. Pregnancy among physicians especially during training presents unique challenges. So pregnant traineees like myself during residency frequently balance long shifts, overnight shooties, prolonged standing exposure risks and emotionally demanding clinical work. But equally powerful is the cultural pressure. Many experience guilt towards colleagues working towards exhaustion or fear that pregnancy may negatively influence evaluations or career progression or may bring about training delays with no salary. The evidence is consistent. Work conditions matter. A large cohort study in JAMAMA network open found that female physicians had higher rates of pregnancy complications compared to non-f physicians. Evidence shows increased risk of miscarriage, preterm birth and hypertensive disorders. And the risk even gets higher with 40 to 60 hours per week or more. And even after delivery, challenges among women continue. Physician mothers often face early return to work while breastfeeding, lack of suitable lactation rooms, and no protected pumping time during hospital rotations, and incompatible on call and duty schedules. I myself have personally experienced breast pumping every 3 hours while running up and down the ward for rounds in the evening and morning after. in between pumping, charting, responding to patient concerns while breastfeeding. So breastfeeding in training can indeed be daunting. Thus, many women stop breastfeeding earlier than intended. And it is not from lack of motivation, but from inadequate structural support. Ironically, physicians who strongly advocate breastfeeding for patients struggle to sustain it themselves, often due to workplace barriers. Addressing these issues requires solution at multiple levels. So, at the individual level, residents benefit from early disclosure of pregnancy and proactive planning with training programs. Self- advocacy is essential because pregnancy is not a limitation but a physiologic state requiring appropriate adjustments. Preparing breastfeeding goals even before delivery improves continuation after returning to work at the support system level. Program leadership and mentors play a critical role. Duty modifications during late pregnancy in the third trimester, supportive peer coverage and shared caregiving responsibilities reduce burnout and protect both maternal and infant health. Finally, change must also occur at the community and policy level. paid maternity leave during residency, flexible rotation scheduling, competency based training completion and protected lactation spaces and normalizing pregnancy as part of workplace sustainability must be considered as workforce investments. When we support pregnancy and breastfeeding among physicians, we are not simply accommodating them. We are strengthening the very future of family medicine. So women physicians do not experience reproductive health as isolated events. It is a lifelong journey and menopause is the chapter we too often forget to talk about. Menopause typically occurs at around age 51 precisely with what should be the most professionally productive period of a physician's career. years of leadership, mentorship, academic promotion, and clinical expertise. Yet, globally, menopause is one of the invisible health transitions among women doctors. Evidence shows that up to 80% of women experience menopausal symptoms and about one in four symptoms severe enough to affect daily functioning. But menopause is not simply the end of menration. It is a neuroendocrine transition affecting sleep, cognition, emotional and emotional control and physical stamina. All capacities essential to safe medical practice. Common symptoms can include brain fog, sleep disruption, mood changes, and fatigue. For physicians, these symptoms intersect directly with professional demands. Imagine managing complex clinical decisions after nights of poor sleep or doing consultations while experiencing hot flushes or preparing lectures while struggling with concentration. Many women physicians report feeling that their professional competence is questioned not because of ability but because menopause remains poorly understood in our workplace culture. Unlike pregnancy, menopause rarely appears in institutional policies. Across health systems, women physicians describe lack of workplace accommodations, stigma around discussing symptoms, and fear of being perceived as less capable. But the silence has consequences. Emerging evidence suggests menopause contributes to reduced working hours, burnout, and in some cases, early departure from clinical practice. For medicine, this represents loss of senior physicians, mentors, and leaders. So supporting menopausal health is therefore not only a well-being issue. It is in fact a leadership and mentorship sustainability issue. Menopause should not mark the silent exit of experienced women doctors from leadership and clinical practice. At the individual level, awareness is powerful. Recognizing symptoms early, protecting sleep and mental health, and using evidence-based treatments, including menopausal hormonal therapy when appropriate. At the support system level, menopause should stop being invisible. Flexible scheduling, supportive colleagues, informed leadership, and physician wellness programs allow women doctors to continue thriving professionally. And at the community and policy level, healthcare institutions must acknowledge menopause as an occupational health issue. Integrating workplace policies, ensuring access to care, and supporting research focused on women physicians. Because caring for women doctors is not only about their well-being. It also strengthens the organization by retaining experience and valuable talent. If there is one unifying message across today's discussion, it is this. Reproductive and hormonal health does not affect women physicians at only one stage of life. It accompanies us across the entire professional journey from ministration to delayed childbearing, pregnancy and breastfeeding and eventually menopause during leadership years. As family physicians, we understand life course care better than any specialty. The next step is applying that same life course perspective to the doctors themselves. Supporting women physicians through these phases in life is not about special treatment. It is about enabling experienced clinicians to continue contributing fully, safely, and sustainably to the communities that we serve. Because when women physicians are supported across the lifespan, patients, health systems, and future generations of physicians benefit. We as family physicians are uniquely positioned to lead this change. Family medicine is built on continuity, prevention, and understanding the social determinance of health. And these principles must also apply to ourselves and to our colleagues. As clinicians, we begin in everyday practice. We normalize physician self-care. We screen our colleagues the same way we screen our patients, asking about menstrual health, menopause, and their well-being. And we intentionally integrate reproductive and hormonal health into everyday primary care practice. As educators, our influence multiplies. We teach trainee that sustainability is part of professionalism. We model boundary setting by taking leave. seeking care and protecting our health. And we mentor younger women physicians so that they do not walk this journey alone. As leaders and advocates, we create lasting change, advocating for flexible training models, supporting pregnancy and breastfeeding friendly workplaces, and influencing policies within our institutions and professional societies. When we protect the health of women doctors, we are not stepping away from patient care. We are actually strengthening the very foundation of primary care systems. When physicians are empowered to voice their needs, we build healthier workplaces, a more sustainable workforce, and ultimately better care for our communities. We have spent our careers caring for women across every stage of life. But perhaps now it is time to ask who is caring for the women doctors. The answer we do together. We care for ourselves. We care for each other. And we change the systems that we work in. So our call to action is very simple because caring for women doctors is not an act of self-interest. It is a worthy investment in the future of primary care. Thank you. Thank you Dr. Jonah for that enlightening session. Please keep your uh do you if you have any questions please type in the chat box and we will address them at the end of the session. Next I would like to introduce our next speaker Dr. Betrice Giling. Dr. Betrice is a family medicine specialist with a masters in family medicine from University Putra Malaysia with over 18 years of service in the Ministry of Health Malaysia. She brings extensive experience in primary care and is currently in advanced specialty in sexual and reproductive health under the Ministry of Health Malaysia. She also has a fellowship in SRH men's health USM. She is actively involved in research with publications primarily focused on women's and maternal health reflecting her strong commitment to advancing quality care for women in the primary care setting. Without further ado, I would like to invite Dr. Beatrice to deliver her session. Dr. Beatrice, the floor is yours. Thank you Dr. Wong for the very kind introduction. Allow me to share my slides. Good afternoon everyone. Now I'm going to talk about mental health. I'm quite certain that in our journey as a physician at some point in our life each of us actually experienced burnout. Maybe we didn't call it at that time. Perhaps we call it as just being tired. it is part of my job or it had been a very tough week but that feeling of emotional exhaustion being stretched out too thin and losing our sense of meaning in work which we once call love that is called a burnout and today I want to talk about how this experience of feeling burnout is not only common but is more complex and especially among our women's physician I would like to highlight here that the definition of burnout while not in the DSM5 criteria as a disorder burnout is described by health organization as a syndrome with three main dimension. We are talking about energy depletion, exhaustion, mental distance and reduce efficacy. We feel incompetent and ineffective at work. However, for a formal diagnosis, as a clinician, we might look for underlying condition like adjustment disorder for depression which also share the same symptoms of burnout and perhaps we may present symptoms such as insomnia, epatici, irritability, chronic fatigue, right? And the causes are primarily linked to unsustainable, unmanaged workplace stress. Basically I would like to highlight here that all our world health organization recognizes burnout but not in the DSM5. What about prevalence? In fact this is a multi- country study Malaysia, Singapore, Philippine, Indonesia. As we can all see here, it is quite prevalent, right? In fact in Malaysia burnout prevalence are more than half. Associated mental health can overlap. Severe depression symptoms 51% anxiety 48%. In fact, burnout has been shown to be strongly associated with severe depression and even increases the odds of anxiety. It is not just tiredness. Often this burnout overlaps with depression and anxiety. higher rates in females according to evidence frontlininer primary care exposure especially during our COVID era. Now why is it female physician the main drivers for women has been shown to have higher rates of burnout due to emotional labor patient expectation caregiving identity and as a women we have a work home role conflict those with family children and we talk about gender bias and leadership barriers they do exist in the real world higher moral distress. As women, we tend to be more emotional. Burnout in female physician is not just a well-being issue. It is a patient safety, a workforce sustainability and a gender equity issue. So why does this matter? Because burnout lead to we talking about our workforce retention and sustainability. Females are shown to more likely suffer from burnout more than men. gender specific but not emotional load. We as women doctors we have higher emotional exhaustion and we often feel that we have lower accomplishment sense women more than men. Occupational and social load we have roles to play at home at work lower work life integration satisfaction versus male patient safety and care quality. Women has been shown that tend to have higher medical errors or less patient satisfaction near Mrs. and also patients harm just for us to ponder upon. You cannot pour from an empty cup. Taking care of yourself is part of taking care of your patient. Self-care is not indulgence. It is a professional responsibility. It is something for even myself to remind myself. burned out. So what should we do? Recognize early. Remember that there are personal psychological signs we should be aware of. Watch for loss of empathy, emotional numbness, irritability towards patients or staff without realizing. Feeling ineffective despite working harder, or the guilt I'm not good enough, I'm not doing enough. I could have done better. We feel dreaded before clinic days waking up today I have to go to work. So be aware of yourself if you have any of these psychological signs right and they are often present as exhaustion reduce professional efficacy even deeper personalization depression as I've mentioned earlier burnout is often overlap with symptoms of depression and anxiety well just a recap according to the SM5 and I'm sure most of us are well aware about this more than five symptoms in the past two weeks including low mood or loss of interest. What are the key symptoms? Sleep disturbance, loss of interest and pleasure, low energy, poor concentration, worthlessness, feeling guilty, psychoot slowing or agitation and the red flag suicidal thoughts. Anxiety clinically relevant red flags for physition. panic, persistent somatic symptoms, palpitation, headaches, sleep disturbance, difficulty in concentrating, avoidance behavior. If we feel that we have any of those symptoms of signs, right? We should screen these symptoms. Burnout, depression, anxiety, they're very commonly overlap among physician. However, we cannot assume that it is just a stress. we should assess them formally. Again, I would like to highlight burnout may coexist with diagnosible depression or anxiety and requires clinical assessment, not just assumption. We have screening tool which are widely used in primary care. We're talking about our woolly GD2, PHQ9, and GD7. So if you see this the risk is rising, you're working faster but you feel that you're less effective. You feel emotionally detached from your patients or you may even avoid difficult consultation and missing error or near miss just for us to ponder. You deserve the same kind of kindness and care you give to your patients every day. Caring for yourself is not stepping away from your duty. It is protecting your ability to continue caring. Now I'm going to move to what are the multi-dimension model management we can do. We are talking about the individual level, the peer support level and the organizational level. So what I put here are those which has been shown there are evidence that can help us. Mindfulness reflective practice can improve burnout residence and sleep quality. There's also apps online digital mental health support. I will give an example for us in a busy clinic primary care with so many patients. We can adapt this is a one minute clinic door pause in between patient perhaps before you press the call button or you call for your next patient. Stop a little while before you open the next patient file or the door. Take three slow breath and you ask yourself what am I feeling now? What does this patient need most from me? Enter the consultation when you are ready with intentional attention. You allow yourself to have time to take a short break. That is mindfulness. The other technique is during the patient encounter, notice body tension, jaw, shoulder, chest, slow speech slightly, maintain intentional eye contact and notice emotional reaction without reacting immediately. End of the day, you finish your busy clinic. You can have a twominut reflection and ask yourself what went well today? What have I done well? What was emotionally heavy for me today? Let it go. What was heavy for me but is not mine to carry home? Whatever it was heavy for you today, leave it there and don't bring it home. What do I need to release before I go home? And most importantly, what is one thing I am grateful for today? Now let's move on to peer team support level and I'm sure everyone you have your friends your close ones right or colleagues that you are closer to at work what work in real clinic peer circles safe venting groups body system for high-risk days or perhaps a senior mentor organizational level now um in Malaysia we have Tanari health program. It is actually designed for community level not specifically for doctors but doctors and primary care providers they can access to this right. So this health program that it is a psychosocial initiative in Malaysia enforcing on emotional well-being inner residence and a community level mental health initiative. While it's not doctor specific but we can assess the service and it has been shown that they do improve mental well-being among more junior doctors. So what are the advocacy point? You know perhaps we can consider depending on the settings in your organization in your clinic you can have flexible scheduling for caregiving doctors protect mental health leave psychological support access anti-harassment policies and of course leadership pathway in other dimension right especially in our Asia specific country there are evidence as well that 92% of um primary I mean healthcare providers use religious or spiritual ual coping. But of course, it needs to be combined with structural solution. You are worthy of the same kindness and care you give so freely to others. Gentle strength includes knowing when to pause, to breathe, and to refill again before you start burnout. Now, I'm going to share a few approach that you may think and you can try. Okay. Self-compassion. It is the closest evidence based to self-reward. Self-compassion inversely associated with burnout, especially emotional exhaustion. Self valuation, recognition, self-reward. Supportive environment can reduce burnout. Self-care is burnout protection. Reward behavior. I will show some examples later. Perhaps you can try this. of sustainable compassion requires sustainable recovery. Level one. Level one micro reward to yourself. Every day 30 seconds to 5 minutes. This can prevent emotional depletion. For example, between patients, you can take slow breath, stretching, walk, drink your favorite tea or coffee in the clinic, step outside for a sunlight, or listen to a favorite song while you're driving to work or back home. 30 second self acknowledgement. That was a difficult consult, but I handle it professionally and well. So, what is the mechanism? It interrupts the stress cycle. So it reduces the emotional carryover. Level two, weekly. What can you reward yourself weekly? 30 to 120 minutes. This can prevent cumulative burnout. Going for a facial, going for a spa, hobby time or perhaps a tea catch up with your colleagues and friends, exercise, yoga. So what is the mechanism behind this? It restores your dopamine and emotional reserve. identity beyond a doctor role which we often forget when we get carried away doing our work. Level three, maybe you can do this once a month, half a day. So this protects your sense of purpose and professional identity. Go to a conference that you enjoy, a CME, but not the compulsory ones. Mentoring your junior, maybe you like to teach, maybe you can have a short trips with your friends. So this strengthen the meaning reduces moral injury risk. Level four deep reset reward. You can do it quarterly a year or yearly. Prevent chronic burnout. Go for a short vacation. Health screening. Personal health review. Take a break. Go for your health screening. Therapy mechanism. This resets the nervous system baseline for a long-term resilience. You can also consider a self-reward prescription pad or a burnout warning sign leather. Which leather level you need. Now a decision too, right? Perhaps you feel that um you are you are feeling a bit tired, a bit stretched out today. Maybe you don't need a level three. You can go for level two. Go for a spa. Go for a walk. These are the example of decision two which I have mentioned. For example, you ask yourself, I feel emotionally drained after one patient. Okay, maybe my reward of level one will do. Oh, I take a walk. I take my favorite coffee. I go out to the canteen to buy a snack and then I come back and resume my consultation. Oh, I feel fatic by several patients, repeated stress. Then you may need restoration level two. Or I feel emotionally heavy, exhausted. I'm so stressed. And maybe you need level three. I feel persistently burned out, dread, anxiety, depressive symptoms. Then you may need level four. Caring for others began with caring for yourself. Your well-being is the foundation of every patient you serve. Our journey as a physician very long. So we have to think about our long-term sustainability, self-care. Don't forget that. Being a doctor it is a gift but before we care for others we should care for ourselves. So with that thank you. Thank you Dr. Beatrice for that insightful and practical session. Perhaps after the webinar we can all go grab our favorite coffee or tea and reflect on what we've learned today. Without further ado our third speaker Dr. Sharifa Shahida Christi so doc is an accredited family physician with the college of family physician Singapore and the Singapore medical association. She brings a strong holistic approach to care combining clinical practice with lifestyle medicine and holds both health coach certification and international board certification in lifestyle medicine. She holds a master in public health and is passionate advocate for addressing social determinance of health. Dr. Sharifa is also a co-founder of the Singaporean Society of Lifestyle Medicine, an active speaker and writer and the author of Higma, a book that promotes healthy aging within minority communities. Without further ado, I am pleased to invite Dr. Sharifa to share her insights. We now welcome Dr. Sharifa to deliver her talk. >> Hi Dr. Wong. Thank you very much for the kind introduction. Hi everyone. Thank you very much for spending your Sunday um Sunday with us. Just give me a second. Yeah. Um okay. Right. So you can see the slides here. Okay. So um hang on. Okay. So um my topic today will be on cardio metabolic risk in women doctors. And while doing this presentation um I was very appalled at the startling figures of uh ASCBD events in women and how likely we are to be underdiagnosed compared to our male counterparts. How the different life stages that we go through are kind of treated in silos instead of together. So while it's very well known that menopause um dramatically increases a woman's risk for CVD events by two to sixfold, we should also bear in mind other life stages that it can also multiply our CVD risks um such as during pregnancy, reproductive years and so on which we'll go through later in the in this session. So I hope with this presentation we will be more attuned to the unique needs of our female patients and our female colleagues and look out for one another to the best of that we can especially in this very stressful profession. Okay. Um so some statistics on female doctors. So right now over half of all uh doctors in OECD countries are female. Um and more than 70% in Baltic countries about 25% in Japan and Korea and in Singapore it's about 73% uh of female GPS uh that that of GPS that are female. And the more common specialties that women generally tend to go into for residency will be internal medicine, family medicine, pediatrics and OMG. And usually these are um sometimes um women are sometimes for forced or like pigeon holed into these softer specialties not necessarily by choice but because of you know sometimes uh the perceived flexibility that um that we need to survive the cultural demands of our private lives which we will go through later on as well. And um so statistics for Asian women. This is the Jade register here. And this Jade register is actually a prospective cohort established in 2007 to enhance diabetes care across 11 Asian countries. And they analyze people with diabetes to study their cardometabolic risk and treatment outcomes. And a recent pull analysis of about a million Asian patients. We found that about two to three uh women are two to three times more likely to die from cardiovascular renal events than men. And this is likely because um of the higher prevalence of central obesity, kidney kidney disease and how we are likely to be underdiagnosed uh for ASBD and also heart failure in women. And in Singapore, it is the number one cause of death in women. Uh and it's not breast cancer like what most people in Singapore actually think. >> Sorry, sorry to interrupt. Um there's a comment that perhaps you can slow down a little bit. >> Oh, okay. Sorry. >> Thank you. >> Okay. So [clears throat] uh it is of this background that we now now dive into the complexities and the paradox of the female caregiver. So the paradox lies in the very fact that um the very qualities that make female physicians exceptional in our work, our empathy, our resilience in navigating complex social webs and also our ability to bridge cultural gaps. These are the same factors that also increase the weight of our our burden in our professional lives. So is this challenge of being a modern scientist in a landscape that still honors ancient social contracts and uh so I thought I would um like to just touch a little bit on the cardabolic spectrum. So this is represents a continuum of risk factors and diseases that link metabolic dysfunction to cardiovascular disease. It progresses from early silent metabolic changes to chronic diseases like diabetes and eventually at very advanced severe heart failure. So this spectrum is often referred to as the cardioabolic syndrome or metabolic syndrome and it is a cluster of conditions that include high blood pressure, dysipidemia, insulin resistance and also abdominal obesity. So what happens is that um with chronic stress like how we have in our um you know which is very common in our clinical environments. It leads to uh persistent vaso construction, impaired barrel receptor sensitivity and all this leads to renal sodium reabsorption which therefore increases our blood pressure over time and women this is often exacerbated by fluctuating estrogen levels and estrogen actually helps with the nitric oxide mediated vaso dilation. So when we don't have that when we're premenopausal when we're postmenopausal sometimes this um nitric oxide vaso dilation um declines. So then it precipitates more vaso constriction and therefore blood pressure that's why blood pressure is um higher in women above age 65 compared to men. So this transitions us um you know into hypertension eventually. And then when it comes to irregular meal patterns and processed hospital food also uh it disrupts our circadian clocks when we have on call shifts we have uh night shifts we're on float and things like that. So it when it disrupts our peripheral circadian clocks this also leads to disruption in our hippatic lipid metabolism and this chronal disruption it impairs the clearance of triglycerides and also reduces the activity of lipoprotein lipase which results in prolonged prospendial lipmia and also this uh unfortunately increases our bad lipid profile and all these hormonal meu it facilitates the stress induced visceral adiposity which are very metabolic ically active and further drives insulin resistance as well. So this is a reminder of the uh metabolic syndrome criteria. So we use a modified NSET ATP3 criteria and sorry uh just to mention that you need three out of five of these criteria to be diagnosed as having metabolic syndrome. Okay. So now moving on to the stress heart connection. We mentioned earlier about how stress can contribute to metabolic dysfunction and heart disease. So the relationship is not just psychological like you think you're stressed and then you know therefore you you you have all these other chronic diseases but actually it's a physiological reprogramming that occurs when the body's emergency system it stays active for too long. So in the medical environment where it's very high stakes, sleepd deprived and you have this moral weight which we'll speak on this connection can become a very significant driver of metabolic dysfunction. When the brain perceives a threat, it activates two primary systems which is the sympathetic adrenal medela exists and also the hypothalamic pituitary adrenal axis which you can see on the top left corner here. So it secretes all these catakolamines your adrenaline or adrenaline. it secretes cortisol as well. So with chronic activation of all these unfortunately the cortisol will trigger higher sugar levels eventually leading to insulin resistance. um the vis cortisol also sorry cortisol also preferentially um deposits visceral fat instead of subcutaneous fat and also further to that um adren adrenaline nor adrenaline it causes um constant surges will increase your heart rate your blood pressure and all this um very high velocity flowing through your blood vessel walls it will damage the endothelial walls and make them more prone to plaque buildup arosclerosis and also blood pressure so the medical workplace is also designed very uniquely designed to disrupt the very metabolic pillars that physicians and nurses recommend to our patient. We operate 24/7, shift work, on call rotation, all this disrupt the cicadian rhythm like we mentioned and this governs nearly every metabolic process and that includes insulin sensitivity, lipid metabolism. Melatonin which speak which usually peaks at night, it helps to regulate glucose and unfortunately when we don't sleep properly, we don't eat properly, we are slowly driving this metabolic markers higher. And I thought I should also mention the moral injury component because this is a very silent back of the mind kind of injury that can slowly eat away at our at ourselves. So it's distinct from burnout which um so moral injury is this distress of being unable to provide the high quality care that we were trained for because of systemic constraints and this can act as a very chronic low-grade inflammatory stressor. And this kind of uh injury was actually one that I personally experienced before the covid pandemic, during the pandemic and even after. And it can eat away at our job fulfillment, our job satisfaction also. And it's a form of chronic stress. So now moving on to the gender specific paradox that contributes to the underrecognition of this excess metabolic associated cardiovascular risk that we see in women. So there are a few stages in our lives um that uh that that warrant um you know more more looking into. So uh some things like pregnancy complications. So if you're naly paris versus multiparity. So nali paris woman they have a lower CBD prevalence only 18% compared to multiparis woman which is about 30%. And women who have five or more children they have a higher CBD uh prevalence about 2.2 times higher than women who don't. and um things like history of preeacclampsia, gestational diabetes, all these are also long-term CBD uh sorry CVD predictors that we should be looking out for as well when we see patients. And um in reproductive years, your early or late minarchy, depending uh on whether you have either one, it also increases your CVD rate. So it's like a J, it's like a J kind of shaped curve. So you want the average age of onset which is about 12 to maybe about 14 cuz once you hit either too young or much later then that increases your risk of CBD um risk and um PCOS polycystic ovarian syndrome that's also an independent risk factor very known to increase your risk of CBD events by about 30 to 40% compared to women who don't have it and also menopause transition. So now there's been a lot of um uh a lot of um traction regarding menopause transition, how it affects CVD events in women, especially in Singapore. We recently have um our menopause guidelines and it targets CVD um adjusting and stratifying women for CVD events as well because we recognize it as the number one um cause of disease in Singapore. So uh menopause transition still remains one of the most overlooked phases in a woman's life because um uh sorry so is this transition is charact characterized by a very precipitous drop in estradiol which also which actually provides for cardio protection and because of that our it disregulates our lipid metabolism. We have higher bad cholesterol. it uh it it makes us have more central obesity because of the visceral fat deposition and so on and also because of the um the wear and tear the endothelial stress it also leads us to have hypertension uh at later age. Okay. So this second shift that we have here is about um beyond clinical hours women physicians absorb disproportionate emotional labor and household management. So this is a compounding stressor that also elevates cortisol. It disrupts sleep and limits recovery time. And this second shift is rarely quantified in occupational health assessments, but it represents a very meaningful and modifiable cardioabolic risk factor. And so these are some strategic interventions that we have for physicians um to for self-care that uh I thought we could we could all uh implement in our lives. So first one is annual screening, metabolic fueling and also micro movements. So for annual screening we ideally should schedule our own annual review including a metabolic lab. Just keep an eye monitor levels and don't be the patient as a do don't be the doctor as patient only during crisis. Um I would we would advise also for strategic BP monitoring. uh you know when you're at home, when you're on your rest days, off days, when you're not um at work, then maybe just check your blood pressure once in a while just to see what your baseline is and monitor it. And also monitor waist hip ratio and BMI as well. And when it comes to metabolic fueling, um we propose for strategic nutrition. So things like high protein, healthy fat packs, nuts, seeds, yogurt, granola, oats, that sort of thing. So something that will actually um nourish our bodies and fuel us better instead of just you know very short pace very um energy burst that kind of um sugar spikes and window eating also is uh is is recommended. So if night shifts are required we align our meals to minimize circadian glucose disruption. Hydration is also very important. Never forget hydration and as much as we can try to eat a rainbow. And micro movements here uh it just refers to like very small movements throughout our day that we can do. So there's a 2020 rule where every 20 minutes of sitting or standing in a fixed position we spend 20 seconds doing calf raises or stretches. So sometimes during a long consults where I have or even short consults actually I'll just like um tiptoe on my when in a seated position I'll just tip toe just to kind of stretch my calves and you know work my zolius muscles as well. So you could do cuff raises even while sitting while speaking to patients as well or like um maybe put your examination couch a little bit further away from your desk and then you can walk to the walk um to the patient to do the examination. So every patient if you can um you know when you do that then that will be like those short micros micro move movements that we do because the short bursts of muscular contraction they actually help to move glucose into the cells without requiring insulin levels. So that's really good for for us to reduce our risk for insulin resistance. Uh if we can um I think most of us are doing this already when we have water rounds we do the stairs instead of elevators but also because elevators take a long time. So um that's what we do also. So we incorporate stairs during morning rounds just to help with this micro movements as well before we sit for the rest of the day. Uh so there's needs as well NEAT which uh which is non-activity non exercise activity thermogenesis. So this refers to the energy expended for everything that is not sleeping, eating or structured exercise. So things like walking, working, fidgeting as well. So like for example uh for if you if you're active then it's about walking to work commuting you take the stairs all these are needs exercises needs activities and then if you use a standing desk uh you pace during calls or you walking to a co-orker's desk to speak to them all these are also uh needs activities. So uh other ways where we can incorporate need also is uh to be less efficient where we try to make extra extra effort or extra trips to put things away or you park further from your hospital entrances or your clinic entrances things like that or when you're on the phone as well simple things when you're on the phone you just stand up and you walk around as well instead of sitting down. So in Singapore I just wanted to highlight um we actually have this uh woman's heart health clinic in one of our public hospitals. So it [snorts] offers a very seamless multi-disiplinary care across various specialties here to address CVD risk factors in women and improve our treatment outcomes. So this is in the hope to bring down our leading cause of death which currently stands at 35%. And so the summary here in conclusion female physicians we are very silent metabolic drivers because our unique life stages like pregnancy, reproductive years and menopause all interact with our chronic professional stress to accelerate our health risk. So we must pivot from self-sacrifice to self-care. We prioritize our restorative sleep. We prioritize nutrition. We prioritize our physical activity. we be smart about it and we try to incorporate it into our daily activities in order to reclaim our metabolic agency and ensure that we ourselves are being looked after while we care for others. Okay, so screen early, screen regularly. Lifestyle definitely helps as well. So with that, I thank you very much for your time. Uh apologies if it was a bit too quick. Uh but you can always reach out to me or you can ask your questions in the Q&A later. Thank you very much everyone. >> Thank you Dr. Sharifa for that comprehensive and informative sharing. Now, is everyone moving their cows and toes getting in those micro movements as we listen to the webinar? Okay, next we have our fourth speaker, Dr. Linwin, who is a practicing family physician from Myamar with a special interest in women's health. She's currently a fellowship candidate with the Myar Academy of Family Physicians. Dr. Li is actively involved in community outreach, conducting reproductive health education and first aid training in public schools, reflecting her strong commitment to preventive care and health promotion at the grassroots level. It is my pleasure to invite Dr. Lingwin to share her insights. Dr. L the we look forward to your presentation. >> Okay. Thank you very much for your introduction Dr. Juan. Uh I would like to share my screen. Okay. Can you see the screen? >> Yes. >> Of course. >> Yep. Can you try to put it to >> Yeah. I am Dr. Lewen, a fellowship candidate from Academy of Family Physician. Yeah. My topic is the physical burden of care, ergonomic strain and sustaining the body. Uh here is my outline. Uh for introduction, female female family physician may experience higher physical and ergonomic burden due to prolongstanding repetitive examination, documentation tax, and extended elect. and uh like uh reproductive problems like pregnancy, childbearing and other associated symptoms and increased risks of muscular symptoms. Uh for prevalence physical burden a man uh physical burden a man female family physician over 54% reporting low physical activity as Dr. Sharifer mentioned uh high rates of overweight, obesity and other cardiovascular problems. Uh mutual contributors include uh lack of time. We don't have uh much time for exercise, much time to uh take care of our diets. Uh it's about 37% and family responsibilities. Uh we take care of our babies, we take care of the families. So it's 38% and burnout as uh Dr. trees mentioned it's often exacerbated by high stress environments. Uh female family physician can face a jewel burden uh clinical physical demands and economic burden like prolonged computer use and documentation additional domestic responsibilities like family problems uh childbearing problems and greater time spent on ear documentation. So we need to have higher rates of walk-related muscularkeeletal problems. Uh we also have occupational stress. Uh Dr. Petrice mentioned about this very much. Uh for family me uh as a study in family medicine residents it correlates significantly with physical symptoms scores. So it has been associated with physical symptoms like it can transform into body symptoms like body pain, low back pain and insomnia. as physical burden. Long periods of standing, walking and moving between patients can contribute to fatigue and lower limbs rate especially in busy outpatient setting and we need to do repetitive tasks like examining patients, writing notes, typing and it can increase hand, wrist, neck and shoulder locking. In physician study, women often report more time spent on documentation than men physician. As Dr. Joanna mentioned physical burden also increase with pregnancy, childbearing, lactation and taking care of babies. Agonomic burden uh in economic burden prolonged computer use can encourage forward posture, rounded shoulders and static steading which are common drivers of neck and upper back pain. In a review of workrelated muscular sculer disorders, female physicians 72% of female proceduralists uh reported woman uh workplace muscular skull symptoms 46.6% than male colleagues. So women may experience more upper related pain than lumbar pain. Why burden is higher? Women physician need to carry more domestic and caregiving duties outside work. So it can reduce recovery time and increase cumulative fatigue. Workplace expectation uh workplace exploitation and emotional strain and we need to do extra and pay tax. So it can indirectly worsen physical exhaustion and muscularkeal discomfort. So we can get more prone to get low back pain and uh muscle tension. So how could how to cope ergonomics? So effective coping strategies include focus on ergonomics include exercise and workload management to prevent burnout injury. So we need to have uh workspace uh adjustation adaptation like we need to correct our sitting posture. So now you can correct just right now. So we need to straighten your back and uh keep close with your back cover and it can reduce your back pain and muscle tension. And we need to take we need to sit uh down now for 1 hour. So it time to stretch. So we need to stretch your neck muscle. We need to stretch your lower back and legs. And we need to stretch your hands and forearms, angle and leg, chest and shoulders. It can uh stretch your muscles and it can re reduce your somatic pain. This is the cycle of poor posture and ergonomic break. So if we have poor posture, it can increase your muscle strain and then if the muscle strain is prolonged, it can reduce pain. It can produce pain. we can reduce mobility and it can lead to postural compensation. So we need to take the we need to break this circle by using economic solution. So we need to use adjustable chair uh standing monitor and uh a monitor arm and then we need to do stretching during the breaks every 30 minutes. So it can improve your well-beings health and wellbeings by breaking the circle. So it can improve your long-term wellness. at management. Female family physician can manage physical strain by prioritizing consistent uh foundational self-care. As Dr. Mitrice mentioned, we cannot pour from an empty cup. So, we need to take care of oursel first. Key strategies include setting work home boundaries, practicing mindfulness. So we need to leave the walk at work and we need to be very peaceful and be left in uh home. But we need to prioritize physical health such as nutrition, sleep and prioritize sleep and nutrition. We need to have enough sleep and we need to maintain a consistent balanced diet, high fiber, high protein diet to sustain energy, minimizing excessive caffeine and sugar. And we need to have schedule rest. Uh incorporate regular breaks or mini breaks during the workday to stretch and decompress and to relax yourself with your favorite coffee or tea. Uh utilize support system. So we need to connect with family, friends or a mentor and engage in hobbies to reduce stress. Uh we need to exercise regularly. Consistency is the key. As Dr. Bri also mentioned that doing exercise can increase your dopamine and it can reduce your stress. It can reduce your muscle spasm and it can reduce your muscle pain. Self-awareness. uh if we need to if we if you have uh some feeling unwell and if you have something uh you need to you need to take care of yourself first. So seek medical care do not neglect personal health care. So find a trusted physician for your own care and do not hesitate to ask for help. Self-awareness, self-care, self-love, self-awareness is beneficial for female family physician. So practice mindfulness, use relaxation techniques such as meditation, deep breathing, yoga. It can reduce your stress and it can manage your stress induced tension. So self-awareness uh there is another compartment modify physical demand. So if necessary reduce work hours or adjust clinical activities to accommodate physical limitations as workplace initiative, we need to participate in worklife initiative. encourage or join workplace initiative life walking meeting on-site fitness program or gym partnership. So we need to foster a supportive team separated walk to share the physical and emotional burdens as a person I want to share my personal experience here. I sustained a knee injury partial MCL care following the minor incidents mean minor accident during the coid9 pandemic. At the time access to surgery and hospital admission was limited. My autobetic surgeon recommended conservative me management with physical physiootherapy and analesia. I remained on bed rest at home for two months and the physical remembration were challenging and had negative impact on my mental health and my mood is up upside down. So after the pandemic I focus on rebuilding my physical strength and mental resilient. So uh with the support of my family and friends uh this is my friend who support me physically and mentally through my journey. I gradually return to a new normal. I continue to do strength training and stretching exercise to strengthen my knee. As a mother of two active boys, I strive to I strive to maintain a healthy work life balance. Now I can pursue what truly matters to me in life. Uh here my reference. Uh thank you all for kind attention. Thank you Dr. Langwin for that meaningful and relevant presentation. Your sharing of your personal experience with the knee injury was especially relatable. I'm sure many of us can identify with similar experiences as well. >> Yeah. >> So, thank you. Thank you, Dr. Langwin. >> Yeah. >> Right. So, let me introduce our next speaker. Last but not least, allow me to introduce Dr. Annie Liu Yaan, who is a family physician based at Taipei Veterans General Hospital. She holds a master's degree in environmental and occupational health science from National Taiwan University and is currently pursuing a PhD in precision health and intelligent medicine. Her clinical and academic interests include primary care, occupational health, and preventive medicine with a strong focus on integrating innovation into patient care. It is my pleasure to invite Dr. Annie to share her insights. Dr. Annie, over to you. >> Okay. Thank you, Dr. Wong. Okay. And let me share my slides. Okay. And good afternoon everyone. And I'm Amy from Taiwan. And today my topic is healing at a cost. We're talking about the occupational exposures and hidden risks for female health care workers. And glo globally uh 17% of the health care workforce is female. But however uh our environments are not built for our uh female biology. So uh let's take a look about the four intersecting pillars of the occupational health and the first pillars will be the infectious disease exposures and the second pillars will be the heat dehydration and the protective equipment that we will also mention later about the personal protective equipment. And the third one will be the reproductive and chemical hazards. And about the ergon ergonomics, uh we have the uh excellent discussions ahead. Okay. So let's take a look about the P1 about the vertical threat and um several biological exposures will carry a double threat for the pregnant healthcare workers and such as the needle sticks or the mucosal contact. They will introduce the extreme risks from the pathogens like the tossoplasmosis, reubella, vericella, hepatitis B or C and HIV. And once the uh female workers under during their pregnancy got this kind of exposure, they're not merely the maternal infections and through the transmission and this kind of um pathogens will trigger the vertical vertical transmission and the damage to the fetus and which would increase the likelihood of a miscarriage, congenital defects and several neurological damage. And the pillar two will be the invisible toxic threats and which might related to the chemical agents and and the first of all the this kind of exposure such as the hemotherapy drugs and this kind of anti-neoplastic drugs their mechanism would will attack the rapidly dividing cells. So it will lead to the lessly toxicate to the to developing fetus and especially in the first trimesters and under list those exposures and also elevates the risks of miscarriage still births and congenital m formations and what's the impact to our fertility? It will directly link to the secondary infertility and also damage our ovarian follicles and create and increase the three times higher risk of irregular me menstrual cycles. And on the other hand u some exposures like inhal inhalation anesthetics and this kind of anesthetics and mostly we use like the nitrous oxides it will cause a long-term the long-term exposure will cause the spontaneous abrion fetal chromosome abnormalities and besides the pregnant pregnancy will act as a toxicity amplifier because during the pregnancy the blood plasma bomb volume will increase and also our bessel heart rate will be elevated and also increase the renal blood flow. So all this mechanism will make us as uh as the toxic toxicity amplifiers and not only we will got the influence while we are getting the exposure from our workplace and and all this toxic exposures they will remain in the mother's body and also through the systemic circulations it would uh affect our breast milk and so this kind of toxicity will also influence the nursing impacts and the pillar three is about the physical restraint and we will talk about the uh uh nowadays our personal physical rest and this kind of restraint is um mostly about male centric So it it was designed maybe taller and broader and is suitable for male but not for the females and uh for the female that our skin might be thinner and more easily to get the allergic reactions. So um so under this kind of design we will not get a really suitable or really feed about this kind of physical re restraint. Okay. And so what's the impact uh what's the impact of this? So while we're wearing a bulky ear feeding and hard to remove PPE and it will related um it's too difficult for us to remove to remove this kind of PPE especially while we go into the restroom. So in my coast, the female health workers, they avoid to get the water and the food intact and they're trying to prevent the need for the restroom breaths. And therefore um it will cause the severe dehydration and maybe headaches, dizziness or extreme fatigues. And this kind of vicious cycle uh consequently will cause the increased uh long-term risk of the heat induced kidney disease and furthermore um through the biological u mechanism while the female health worker under the pregnancy u our body temperature will increase up to 1.4° 4° C and on if and if we wear the PPE and which is heavy and not breathable um our body temperatures um might exceed uh sorry the environments um the temperature might exist 29 degrees Celsius and also which cause the heat stress and so biologically to prevent and the mental overheating, our body will try to divert the blood flow away from the internal organs to the skin surface for cooling. And this kind of a mechanism uh on the other hand will decrease the buff to the placenta and trigger the severe fetal stress and maybe abnormal hot rest and which will cause the damage to our fetus. So um so after all this discussions we might to rethink our the uh occupational health for the female health workers. So the current model would be like the male default model and all this PPE or all this exposures they may not cause the kind of damage damage of males. However, we were trying to we need to try to think about the gender responsive model and such as we might could have the customized PPE and especially for female workers and maybe it's shorter and narrow narrower and is more feeding more easily to remove and second about the exposure of the possible like infection disease or the chemical exposures and we need to set the limits and the regulation especially for the pregnancy and pregnancy and the breastfeeding female workers and and then uh we need to safe we need to set the safety limit and the safety guidelines for all lesb workers. So in conclusions, the true occupational safety must be biologically liberate and by dismantling systemic bi blind spots and mitigating the hidden hazards faced by female health workers, we protect not just our essential workforce but also the generations that carry. So here's my presentations today. Thank you. Thank you Dr. Annie. Okay. So as we come to the end of this session, I would like to extend my sincere appreciation to all our speakers today for their valuable insights and engaging presentations. Thank you once again for your time, expertise, and contribution to today's discussion. We will now open the floor to questions. Feel please feel free to type your questions in the chat box and we'll address them in the Q&A session. Also I think on the floor today we have um a few um women that is not contributed much in like the uh the the the women working party. So we have Dr. Hina Jaw who is the global uh chair for the working party for women and family medicine who is in our audience today and also the president-elect uh and as well as the past chair of women working party Dr. Eileen Espina, glad to have you all in the webinar today as well. Thank you so much. So, do we have any questions from the audience? Okay. Perhaps I will allow Yep. Okay. Yep. I will I've already enabled Dr. Hina. Yes, you may unmute. Uh hi uh good morning, good evening, good afternoon wherever you are. Sorry I'm a bit jetlagged. I've just returned from UK back to base in Lahore, Pakistan today. Um we've got uh Dr. Marjgerie Cross in the audience as well and she has um given a very excellent [clears throat] comment in the chat box and I just want Marjgerie to kindly introduce herself and highlight a bit more on the rather stress on the comment that she's just made. Um and I think we must utilize the forums such forums to talk about any hot topics issues and if we can take home uh a number of messages back to our practices and help our communities grow. So Marjgerie the floor is yours if you want to just explain your comment a little bit more. Thank you. >> Well first of all that's been an extraordinarily interesting afternoon. Thank you very much. very very well-run, very interesting topics. I just wanted to um put in a little bit about some research we've done in rural New South Wales and that's about the types of uh consultations women GPS in our country get. uh mental illness is more common and more severe in rural Australia but there is a critical shortage of rural psych psychiatrists particularly in child and adolescent psychiatry a worsening shortage of GPS etc and so young women doctors in particularly in our country get a disproportionate um amount of mental health consultations and I think we have to work very hard in my country anyway to um support young female GPS who may feel underprepared for the complexity of mental health care they required required to provide um so early in their career and that also contributes to burnout and frank mental illness in this cohort. So, it's a little study. It's in our area, but I just didn't hear it come up amongst what you've said today, but an excellent session and so well presented and well moderated. Thank you for allowing me to talk. >> Thank you. Thank you, Dr. Margie. Perhaps um since you presented on mental health, do you have anything you would you would like to comment or add on? >> Thank you, Dr. W. Um I think, um at the moment, no. Okay, thank you. So, thank you for sharing your insight as well. Yeah, I I do agree. Sometimes we a lot of the things why we come up with the topic of this webinar is we realize that a lot of the things that are designed to suit the male but um it's not towards the female population. So hence we have this you know we want to have that emphasis that be it mental health be it physical cardioabolic women have our own specific risk that needs special attention and needs to be addressed as well. Okay so do we have any questions from the floor okay Dr. Hina, would you like to is there anything you would like to add on? >> Um, yeah. I mean, I'm I'm thinking if we have to raise the bar a bit higher, uh, by we, I mean the female family physicians and actually hit the nail on the head by speaking about some of the things which we try not to speak about. Um there are lot of our um female workforce who is in a relationship I'm talking about the personal levels which may be affecting the profession. So, and I I attend a lot of sessions and I and I wait for that that slide, those words, those off the hot off the press topics that are to be included, but I just feel like we all um take uh it's not not just this regional presentation. And I've seen a number but I think if we talk about the equity the violence abuse discrimination and all all that ambit if you want to cover then as female workforce we are representing a huge population of female workforce. So should we be bringing those topics and opening the floor for that as well? I don't know what the audience feels about it. uh but uh yeah we just need to come out of that the hiding and the sugar coating and uh the different things and just explicitly provide a forum where we can talk about obviously with dignity and respect and maintaining integrity as well. Thank you. >> Thank you Dr. Hina. Perhaps yes this that is uh something we can definitely look into in the future. Okay. Um we have Dr. Een here as well, the president-elect of uh Wonka APR. Dr. Eileen, do would you like to a word or two? >> Yes. So, good afternoon everyone and good morning or good evening wherever you are right now listening. First of all, I would like to congratulate the working party for women in family medicine in the Asia-Pacific region led by uh Clarice and the wonderful speakers here uh this afternoon. Picking up from what uh the chair of the working party has mentioned, um I was thinking that maybe uh we could um push this further in the in the region by coming up with a framework for uh gender equity in family medicine uh gender equity for action and reform in family medicine so that uh we could have an an inclusive and resilient primary care system where women family doctors would be able to thrive as clinicians, leaders, educators and system shapers. Um, I think you will all agree that uh the participation of women especially in leadership positions in family medicine in the Asia-Pacific region is not the same in the differentations of of Wanka in the Asia-Pacific. Um maybe in the Philippines it's much stronger in Australia where Marjgerie is from uh we have a lot of women leaders but we cannot say the same for other countries. Uh I see you nodding uh your your head. No. Um so there is really a lot of work that that needs to be done within our region and what Hina mentioned is also something that uh we can take on uh as we progress and as we strengthen uh our networks within um the working party in Asia-Pacific. So all I could say is that we have our work cut out for us in the coming years and I hope that you could continue with this level of um enthusiasm and with the same level of commitment. Uh you can expect my support as president-elect for the region as we continue pushing for um equit gender equity and uh women health issues in the Asia-Pacific region. And again my congratulations. Thank you and good afternoon. >> Thank you. Thank you Dr. Eileen and thank you for the idea. So we will definitely look into it as well. And I think Dr. Sarah Rashid uh commented recently in Pakistan the government has proactively focused greatly on women's right all over in all the departments. So yeah, I I think I do agree, you know, as um in Asia-Pacific region perhaps, you know, due to the cultural belief and and differences, there's still some uh countries where women are, you know, probably not enjoying or you know uh the same equity rights as other countries such as Australia, um Singapore. Yeah. So I I think definitely yes we we can have like a you know future perhaps like a forum or discussion that we can uh invite all these other countries to actually speak up more about any problems or any issues faced in their own countries. Yeah, >> we we could probably start by ensuring that we have representatives or we have uh more active participation from all the member organizations in the Wanka Asia Pacific region from the northern hemisphere from Mongolia all the way down to Fiji. uh because I I think right now even with I I see Jello in the audience um even in the Raja Kumar movement we still don't have um complete representation from all our member organizations uh in in the different working parties and and even in the Raja Kumar movement but this is a very good beginning and I'm very happy as former chair of the working party to see that finally this is taking off in my home region and congratulations and thank you so much for all your hard work. Uh I'm Delaney from uh I'm the chair for the women's working party for South Asia region and I would like to congratulate claris for the wonderful webinar that you all have organized and it's wonderful to see how the Asia-Pacific region women's working party has grown and [clears throat] congratulations uh claris for all that hard work and hi to uh lovely to see you here in the forum as well it's nice that uh you are supporting the women's working party Asia-Pacific region. I think I met you at the collaboration hub at the world conference. So nice to see you here Ellen. So congratulations once again. Well done Clarice and the team. >> Thank you. Thank you Dr. Delini. >> Okay so um just to recap we have almost 100 participants today. So thank you so much everyone for your time and all the comments you know and thank you for my um speakers you know my lovely girls. So thank you very much. So do we have any more comments or any questions? If not we will just call it a day. Okay perhaps if everyone can on their camera we can just have a quick photo session. If anyone that is convenient, you may on your camera and then we can have a photo together. >> The camera has been disabled. We cannot >> Oh, okay. Right. Sorry. Um, let me try and Okay, hold on. Um, okay. Yep. You should be able to open your camera now. Okay. Thank you so much for being part of the webinar. We hope there's more to come. >> Sorry uh some of us weren't ready. So can we uh >> Yes. Yeah. Okay. Are we ready? Maybe I'll >> No, no, no, no. >> We wait for you. >> Sorry. I know you all are in rush but yeah. >> Okay, Dr. I prefer my my profile picture. >> Okay. All right. Okay, sure. Okay, >> the camera smile. One, two, three. Okay, hold on. There's a few more pages. Let me move to the next page. Okay, one, two, three. Smile. Okay, lovely. Okay, thank you so much everyone. So, um when you leave the uh chat, you know, you will be directed to a survey. Please fill it out for your e certificates. Okay. All right. Thank you very much and have a nice weekend. Goodbye. >> Goodbye. Thank you. >> Thanks everyone.