It’s a question many health professionals have been considering amid the pressures of Canada’s health care crisis: Should I stay or should I go?
In a May 2023 survey by the Ontario College of Family Physicians, 65% of respondents cited plans to leave office-based family practice or reduce their hours in the next five years.
Results from the CMA’s 2021 National Physician Health Survey (NPHS) showed that 51% of all the practising physicians surveyed were likely or very likely to reduce or modify their clinical work hours in the following two years.
Some possible explanations: high rates of burnout, depression and low professional fulfillment.
So, why keep coming to work?
The CMA spoke with Dr. Jillian Horton, an award-winning physician, author and physician health and wellness expert, ahead of her appearance at the 2023 Canadian Conference on Physician Health in Montreal.
You’re moderating a debate about staying or leaving the medical profession. If you had to make the argument to leave, what would you say?
One of the challenges in medicine is that we’ve historically relied a lot on sacrifice — asking people to continually invest their life’s energy to keep the health system functioning. The pandemic has shown us that there’s not necessarily an end to that state of chronic emergency. Without a complete change in strategy, a different kind of leadership and a shift in priorities when it comes to delivering care to patients, nothing will be different.
I think that has caused physicians to pull back and say, “I have one life and how do I choose to spend it? Will I ever be able to do enough by investing that time and energy in health care versus perhaps investing it somewhere else?”
Why should physicians stay?
I think most of us know that on a good day, medicine is a wonderful way to spend our lives. And a good day isn't where you've just had good outcomes or where amazing things have happened or it's been easy. A good day is when we feel our work is meaningful, when we have the opportunity to fulfill something aligned with our true purpose, the real reason we chose the profession.
A job with meaning has the capacity to sustain us throughout our career, provided the working conditions allow us to both survive and thrive.
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In your book, We Are All Perfectly Fine, you talk about the “flawed” health system. How is that affecting physicians’ ability to thrive?
Part of the current dysfunction in the health system relates to leadership, how health care is organized and delivered, and to environments that are not relational or don't encourage communication. The biggest drain on physicians is the administrative burden — repeating the same clerical tasks that could be performed by people who haven't had to learn our skill sets.
We are losing so much cognitive power, skill, energy and time doing those things, that by the time we get to clinical care, sometimes there are too few brain cells left.
That's not in the best interests of patients, and it's really demoralizing for clinicians.
When physicians are burned out, patients suffer. When physicians are burned out, organizations suffer. That's one reason why this professional fulfillment piece is so critical.
What should medical students know before they sign onto a career as a physician?
Medical students would do well to consider what they find most meaningful about the work they’ve done so far. Perhaps it has to do with a procedure, alleviating a systemic problem, clinical research or connecting with patients. Prioritizing meaning helps give us a little bit of immunity against burnout. It's not a cure-all and it can only go so far, but when we lose a sense of meaning and connectedness to our purpose, we're really in trouble.
The CMA’s NPHS showed that women, medical residents, caregivers of a child or parent and respondents working in a rural or remote area were significantly less satisfied with their current jobs or training positions and experienced more negative wellness outcomes. Is there a specific solution to help retain these at-risk groups?
First, we need to validate their experiences in medicine. We need to create national dialogues where health leaders come out and say, “This isn’t just somebody’s ‘opinion’, this is a real phenomenon and it is undeniable.
This is what it’s like to be a woman in medicine in a historically patriarchal system, to be a person of colour surrounded by people who aren’t BIPOC and have no idea of the additional burden you carry, to be dealing with a disability and feel you must hide it or function with it despite an unforgiving environment or struggle to get appropriate accommodations.
We need organizations like the CMA and other national counterparts leading and normalizing these conversations, and then we have to follow up with policy changes. We’re very good at creating standards for many other things in medicine but haven’t caught up when it comes to establishing equitable practices for many groups.
One of the CMA’s areas of focus is supporting the physical, psychological and cultural safety of health professionals. What role does safety play in ensuring that doctors will continue to show up for their patients?
Let’s start with physical safety. Physical safety is not a given for some physicians. In emergency departments, for example, they are experiencing all kinds of aggression and sometimes threats, and that is a huge impediment to being able to do your work and believe that your work is meaningful. A lack of psychological and cultural safety poses the same kind of threat, although we don’t always understand or acknowledge that.
One interesting thing we know from the literature is that the people who are the most empathic, the people we most want to deliver that compassionate care to us and to our families, are the ones who sustain even more injuries from working in environments where they see a lot of rudeness, a lot of interpersonal cruelty, and disrespect.
The other thing we know is when people receive culturally safe care, they get better care. They have better outcomes. And, we always say in medicine, one of our priorities is ‘excellence’. And culturally and psychologically safe working environments are a critical foundation for delivering excellent care to patients.
Affordability and housing are at the forefront of public discourse right now. Why does physician fulfillment matter in this context?
We need to help the public understand why that question is so important. A doctor in an unworkable environment may struggle to care for them in a way that is satisfactory to both the patient and the doctor in terms of meeting the basic goals of care. That is part of what threatens fulfillment.
So, we're not talking about financial gains, or physicians being happy with their incomes, we're talking about - is my physician satisfied with their work and able to do a job they’re proud of? Do they have enough time to complete everything during their clinical day or are they worried about missing things? Are the cognitive and emotional loads too heavy?
If physicians don't experience job satisfaction, they aren’t going to continue to give the 110%, 150%, 200% that the medical system has counted on. When physicians are burned out, patients suffer. When physicians are burned out, organizations suffer.
That's one reason why this professional fulfillment piece is so critical. It offers us a roadmap that is aspirational, so when we feel overwhelmed by a health system that is broken, we don’t just check out or walk away.
This interview has been edited and condensed for clarity.