Christy Stephenson is a family physician in Kingston, Ontario.
As the COVID-19 pandemic marches on, calls for physicians and residents in Canada to safeguard their wellness and promote resilience by “maintaining balance” are ongoing. Recently, we have mourned the tragic loss of a colleague in Quebec. In a study published March 3rd 2020, Ferguson and colleagues found the prevalence of burnout among resident physicians in Alberta to be as high as 69%. And the Canadian Association of Emergency Physicians reported that, out of their respondents, 14% had contemplated suicide within their careers, and 6% had thought of it within the past year. So calls for physicians’ mental health to be protected are important. However, despite growing recognition of the problem, and improvements in faculties’ wellness curriculums, achieving the elusive state of balance and wellness is impossible for many learners and practicing physicians.
Balance, as I understood it in my former life as a gymnastics coach, is achieved when the body of mass is centered over the base of support. When the center of mass tips beyond the edges of this base, you fall. There are several ways to correct this: contain your mass by pulling everything in tight; extend your limbs in opposite directions to create complementary forces; or, most simply, enlarge the base of support.
I can imagine a career as a physician as the center of mass, while one’s life outside of medicine serves as the base of support. As the career expands into longer hours, more extensive clinical and administrative demands, larger practices, and higher patient expectations, the base often shrinks at the same rate. Balance becomes near impossible to achieve and a fall is unavoidable.
Wellness, and the balance required to achieve it, is so highly regarded among physicians that the governing bodies have attempted to mandate it. The Royal College of Physicians and Surgeons of Canada incorporates it into its “Professional” domain of the CanMEDS roles. These are the core competencies that a physician must have in order to effectively meet the health care needs of the people they serve, and includes “a responsibility to self in order to serve others” and “resilience for sustainable practice”. The relationship between self care and patient care needs little explanation – it is obvious that a physician who has not slept or eaten is likely to pose a risk to patients or, at very least, perform sub-optimally. However, medicine is a field where training and service requirements often preclude adequate sleep and meal time, let alone time to exercise, practice any form of spirituality or nurture relationships outside of medicine. While it sounds progressive, effectively mandating wellness through the CanMEDS roles may be entirely counterproductive. It forces entanglement of those activities that a physician does for themselves with the endless expectations for professionalism and patient care, which essentially pulls from the base of support to add to the toppling load above.
Though there are outliers, there is a culture among physicians and, I would argue, an expectation from the general public, that being a physician isn’t “just a job”. However clichéd, the idea of a “calling” is widespread. For some it may be true. For others, it may be a truth they’ve created and lived in to survive the rigors of applying to and completing medical education, matching to a certain specialty, and truly caring for patients under a system that fails to recognize what this entails. If it were “just a job”, the work would end at handover, and the mental space dedicated to the needs of patients could be reassigned to other things, other people, other passions. Meeting the standard of care would always suffice. However, we know this isn’t the case and that, if it were, patients and families would suffer. Physicians would suffer too, because it is often the “superfluous” moments of humanity and care which lend meaning and fulfillment to this work. This idea of a calling justifies, right or wrong, the insidious spread of the career into the further reaches of one’s life.
While focusing on personal wellness and cultivating those aspects of oneself that exist outside of medicine is sometimes encouraged, the idea is fundamentally discordant with the way we work, learn, and are encouraged to identify with this “calling”. As a resident, I struggled with this paradox endlessly and found myself hesitant to share my interests and pursuits outside of medicine with more senior physicians and colleagues. Often, admitting to a life outside of medicine – time spent developing or maintaining my base of support – felt like a loaded and potentially dangerous proposition. I feared revealing a selfish desire to disconnect from the “calling” or outing myself as lazy, unmotivated, or unprofessional. Now, as a staff, with more autonomy over my schedule than I have ever had, the same feeling persists, and I now see it reflected in the residents with whom I work.
In the middle of COVID-19’s second wave, we continue to work longer hours, with fewer resources, and more constant worry. This, at a time when the usual opportunities for exercise, social connection, and disconnection from occupational stress are greatly restricted. For learners, the light at the end of the tunnel may not be as bright, as licensing exams, job prospects, and even the practice of medicine itself are cloaked in a fog of uncertainty. “Future orientation”, I can only imagine, is at an all time low, because the future is disorienting, at best. Limbs flailing, we are balancing on the tip of a finger.
It is impossible to avoid discussion of COVID-19, even outside of the workplace. That said, from the beginning of the pandemic, I have found the widespread understanding among physicians that “this will be hard” both heartening and inspiring. There has been no “admitting” we are struggling even as we are all struggling. We are leaning on each other, and offering ourselves to be leaned upon knowing it will get harder but we need to make it out the other side.
The magical thing about balance is that, when one balancing object leans on another, the base becomes more than the sum of its parts, encompassing the space between them to create stability greater than either could have achieved alone.
“Balance”, at least static balance, likely isn’t achievable right now – and I argue it never was. It may be the perfect time to abolish the fallacy of “balance” in medicine, and take the opportunity to explore and genuinely encourage those activities, still available to us within this time of uncertainty and unending workload, which support wellness. Take breaks, breathe, drink water, go outside, eat lunch, laugh and cry together, relish in moments of humanity, and be extra kind to each other. Consider the harm done by entangling wellness with professionalism, and start changing the culture of medicine to support true resilience.
Broaden and nourish the base of support. Be expecting and accepting of a need for continuous adjustments and occasional, inevitable falls. Know whose hand is there to help you get back up – and offer that hand when you can.
Peter
I appreciated this blog post greatly and wonder how a sense of belonging, which is a human necessity, might be lacking in our profession and be a missing support mechanism for our strength of balance especially in such difficult times. Sense of belonging in medicine in general is something I believe has deteriorated over time.
Dr Jim Stephenson
Hmmm. Too many of these replies grinding their own axes.
I will keep mine short and to the point. Excellent article with much to consider.
I was fortunate enough to be involved in the education of this young professional and am not surprised at her eloquence.
Jennifer Douek
I hadn’t thought of it this way and it’s an excellent point. Incorporating physician wellness into professionalism brings to mind the “healthy food” initiative in my hospital. We now have a contract with a food service company that includes mandatory “healthy” foods so that when I’m hungry, I have (only) the benefit of such options as lentil chips, $4 energy balls and bottled water to the exclusion of familiar and affordable foods. (For background I’m a kale-smoothie swilling vegan and these things are largely unappealing, even to me.) Neither initiative truly promotes health while both narrow our base of support even further. They are, to use a word that has come into vogue of late, performative.
Dan Horvat
Thanks for the excellent article Christy. You highlight a critical topic. I agree with John’s comment. Aside from what we can do to deal with stress better, physicians must also consider how the system in which we work causes stress. There are health care systems that are structured much better than ours. Such systems support physicians, and others, to work together better to get better results in more sustainable ways. I know this is hard, on top of everything else, but somehow physicians need to find ways to advocate for such a system. It will be better for us and for those we serve.
Andrea Lum
Thank you for your authentic article, balance is tough in gymnastics, consider “work life integration”. We built and launched during COVID our Schulich Wellbeing Program Peers for Peers with regards to your last sentence “Know whose hand is there to help you get back up – and offer that hand when you can.”
Ediriweera Desapriya
According to National Academy of Medicine (NAM) report rightly advises health care community to adapt, clear strategies, both as health care leaders and as individual clinicians during this challenging time, to help sustain the well-being of clinicians amidst the COVID-19 outbreak:
Strategies for Health Care Leaders and Managers
Value clinicians: Provide clear messages that clinicians are valued.
Communicate best practices: Communicate best practices clearly and compassionately. Manage expectations, create work schedules that promote resilience, ensure appropriate working hours with breaks, emphasize the importance of self-care, and provide sufficient resources.
Monitor and promote clinician well-being: Monitor the well-being of your clinicians proactively; identify mental health professionals and counseling options available to support them.
Provide a supportive and blame-free work culture: Implement a psychologically safe environment for clinicians to openly discuss vulnerability, stress, burnout, and other barriers to their well-being.
Enable cooperation and collaboration: Institute mechanisms for cooperation and collaboration between management, clinical teams, and clinicians.
Provide a central access point for updated information, technical updates, and tools to address COVID-19.
Ensure clinicians are not required to return to work during dire situations and provide appropriate resources if clinicians are infected with COVID-19.
Strategies for clinicians
Meet basic needs: Eat, drink, sleep, and exercise regularly. Becoming biologically deprived is risky and may compromise your ability to care for patients.
Take breaks: Whenever possible, give yourself a rest from patient care with comforting, fun, or relaxing activities.
Stay connected: Give and receive support from your colleagues to avoid isolation, fear, and anxiety.
Respect differences: Recognize and respect differences in yourself, your patients, and your colleagues, such as needing to talk versus needing to be alone.
Perform self check-ins: Monitor yourself over time for any symptoms of depression or stress, such as prolonged sadness, difficulty sleeping, intrusive memories, and/or hopelessness.
Honor your service: Remind yourself and others of the important and noble work you are doing.
REFERENCE:
1. National Academy of Medicine. Action collaborative on clinician well-being and resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being/. Accessed Feb. 09, 2021.
Ediriweera Desapriya
Great article and thank you for your timely valuable contribution. Recently I was reading a somewhat related article published in the JAMA and furthermore this viewpoint is rightly define, burnout as a complex and interwoven by product of clinicians loneliness and social isolation; inadequate support from colleagues and leaders; lack of a sense of safety and community; paucity of long-term mentoring relationships; highly competitive medical and academic cultures; humiliating and demeaning treatment of nurses, residents, and students combined with incivility and lack of respect throughout the workplace; insufficient time to connect and form meaningful relationships with patients or to maintain supportive and caring relationships with colleagues; poorly functioning teams; and insufficient recognition and appreciation for one’s contributions.
According to National Academy of Medicine (NAM) report even before the COVID-19 crisis, many clinicians already faced burnout, as well as stress, anxiety, depression, substance abuse, and even suicidality. Now this global public health emergency is presenting clinicians with even greater workplace hardships and moral dilemmas that are very likely to exacerbate existing levels of burnout and related mental health problems.
This report rightly advises health care community to adapt, clear strategies, both as health care leaders and as individual clinicians during this challenging time, to help sustain the well-being of clinicians amidst the COVID-19 outbreak:
Strategies for Health Care Leaders and Managers
Value clinicians: Provide clear messages that clinicians are valued.
Communicate best practices: Communicate best practices clearly and compassionately. Manage expectations, create work schedules that promote resilience, ensure appropriate working hours with breaks, emphasize the importance of self-care, and provide sufficient resources.
Monitor and promote clinician well-being: Monitor the well-being of your clinicians proactively; identify mental health professionals and counseling options available to support them.
Provide a supportive and blame-free work culture: Implement a psychologically safe environment for clinicians to openly discuss vulnerability, stress, burnout, and other barriers to their well-being.
Enable cooperation and collaboration: Institute mechanisms for cooperation and collaboration between management, clinical teams, and clinicians.
Provide a central access point for updated information, technical updates, and tools to address COVID-19.
Ensure clinicians are not required to return to work during dire situations and provide appropriate resources if clinicians are infected with COVID-19.
Strategies for Clinicians
Meet basic needs: Eat, drink, sleep, and exercise regularly. Becoming biologically deprived is risky and may compromise your ability to care for patients.
Take breaks: Whenever possible, give yourself a rest from patient care with comforting, fun, or relaxing activities.
Stay connected: Give and receive support from your colleagues to avoid isolation, fear, and anxiety.
Respect differences: Recognize and respect differences in yourself, your patients, and your colleagues, such as needing to talk versus needing to be alone.
Perform self check-ins: Monitor yourself over time for any symptoms of depression or stress, such as prolonged sadness, difficulty sleeping, intrusive memories, and/or hopelessness.
Honor your service: Remind yourself and others of the important and noble work you are doing.
REFERENCES:
1. Southwick SM, Southwick FS. The Loss of Social Connectedness as a Major Contributor to Physician Burnout: Applying Organizational and Teamwork Principles for Prevention and Recovery. JAMA Psychiatry. 2020 May 1;77(5):449-450. doi: 10.1001/jamapsychiatry.2019.4800. PMID: 32074385.
2. McKenna KM, Hashimoto DA, Maguire MS, Bynum WE IV. The missing link: connection is the key to resilience in medical education. Acad Med. 2016;91(9):1197-1199. doi:10.1097/ACM.0000000000001311PubMedGoogle ScholarCrossref
3. National Academy of Medicine. Action collaborative on clinician well-being and resilience. https://nam.edu/initiatives/clinician-resilience-and-well-being/. Accessed Feb. 09, 2021.
Malcolm M MacFarlane
Excellent article. I would note that one of the ways we could broaden the base of support during covid is through employing Internationally Educated Health Professionals (IEHPs). Sadly, as the article linked below reports, despite 2,660 IEHPs signing up through Ontario’s Health Workforce Matching portal, only 20 have been placed. It’s sad that this valuable resource is being so badly underutilized while our health care providers are burning out. One has to ask, “Why?”
https://montrealgazette.com/news/where-are-the-internationally-trained-medical-professionals-in-ontarios-pandemic-response?fbclid=IwAR0UyzHLuy9xjQBucs2xFAyuhYE0oqAuXS-3zp_IiKxU4PaNZnskbfPH_R4
gfotyers
Licencing people with a medical degree, including from a Western Medical School, who are unable to understand either national language or pass basic exams will only make Canadian health care even worse. Do you think our buroacracy so bad that that qualified people are turned away. There is also a problem with stealing health care workers from areas of greater need.
Malcolm M MacFarlane
Just came across this reply. Even though it is delayed, I think a response is warranted.
The short answer is, “Yes, I do think our bureaucracy is so bad that qualified people are turned away.”
Let’s just look at those internationally trained medical professionals who are eligible for the Canadian Residency Matching Service (CaRMS). Each year about 1,400 eligible International Medical Graduates (IMGs) are unable to match to Canadian residencies because of restrictive eligibility criteria.
Far from being “unable to understand either national language or pass basic exams, ” these 1,400 individuals have passed standardized language assessments, as well as objective assessments of medical competency such as the MCCQE1 and the NAC OSCE.
Many are graduates of prestigious schools in Australia, Ireland, the UK, and other countries. Many have practiced medicine abroad. They are competent, capable, and have much to offer. They are also all Canadian citizens or Permanent Residents and deserve an opportunity to practice their careers rather than being marginalized because they trained outside Canada.
Sadly, your reply perpetuates a myth that internationally trained health professionals are less competent and capable than those trained in Canada. This is simply not true. There are many research studies that demonstrate that outcomes for internationally trained physicians are comparable or superior to North American trained physicians. When 5 million Canadians are without a primary care provider, and when we are facing increasing health care provider burnout during a pandemic, we can no longer afford to buy into this myth.
Utilizing these valuable resources can only make Canada’s health care system better; not worse, as you fear.
John Van Aerde - Can Soc Physician Leaders
Very balanced writing! Thank you. CanMEDS makes “balance” the responsibility of the individual, which is important, but the biggest pressure comes from outside, from the health(care) system. What opportunities does the syndemic create to redefine the role of physicians within that system and how do we influence changes in that system? Let’s not forget, all together we ARE the system.
Margaret Burnett
Well said. Thank you for this refreshingly honest article which articulates the incongruity of the situation in which we find ourselves.