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How we’re doing. Really.

August 25, 2022 CMA

Burnout, depression, anxiety: These are long-standing challenges within medicine. But since the pandemic was declared, physicians’ mental health has continued to deteriorate. Now, new health and wellness data from the Canadian Medical Association sheds light on the seriousness of the situation.

"I've never seen so many physicians feeling so demoralized by the system and so deeply burnt out. I think we are in dark times, but I still have optimism because my colleagues remain committed to being at the table to try to make things better." – Dr. Katharine Smart, CMA past president

On this episode of Sound Mind, Dr. Katharine Smart joins host Dr. Caroline Gérin Lajoie to reflect on a year of doctor-to-doctor conversations across the country while advocating for physicians’ well-being.

This episode is available in English only.

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The opinions stated in Sound Mind are made in a personal capacity and do not reflect those of the Canadian Medical Association and its subsidiaries.

Topics

Burnout Resilience Building a case for support Physician health and wellness data

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How we’re doing. Really.

Dr. Caroline Gérin-Lajoie: Welcome to Sound Mind, a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gérin-Lajoie.

On July 25th, 2022 40 physicians at Toronto St. Joseph's Health Center sent a stunning letter to management. They wrote that their emergency department was in crisis, which was threatening patient care and safety. They also highlighted the impact on physicians and healthcare workers. "We witnessed a demoralized, frustrated and burned out staff," they wrote, "the department is routinely an unsafe space for professional practice as well."

The state of affairs is not unique to this hospital. The CMA's 2021 National Physician Health Survey echoes many of their concerns. It found more than half of physicians and medical students surveyed have experienced high levels of burnout. Nearly half screened positive for depression and nearly half are considering reducing their clinical hours in the coming months.

Over two seasons of Sound Mind we've tracked the serious impact the healthcare crisis has had on physician wellness. For this final episode of season two, we are taking a broader look at how Canadian physicians are coping. Nobody is in a better position to relay that big picture than Dr. Katharine Smart, who just finished her term as president of the Canadian Medical Association. Over the past year, Katharine has met and listened to hundreds of physicians, worked alongside nurses and other healthcare professionals to try and solve a health workforce crisis and advocated for action at all levels of government.

Katharine, thank you for joining us.

Dr. Katharine Smart: Thank you so much for having me.

Dr. Caroline Gérin-Lajoie: We called this episode, How We're Coping, Really. How would you say doctors in Canada are coping?

Dr. Katharine Smart: Well, unfortunately, I think doctors in Canada are really struggling right now. How are they coping? Well, I think they continue to cope in that they continue to show up for their patients and for each other. And I think that's really, what's incredible about healthcare professionals and physicians is that resiliency. But I think what's changing right now is how people are actually feeling behind that ability to keep showing up and putting one step and one foot in front of each other.

I've never seen, I don't think, so many physicians feeling so demoralized by the system and so deeply burnt out. So I think we are in dark times, but I still have optimism because I'm still amazed by how my colleagues keep trying and maintain optimism for the system and remain committed to being at the table to try to make things better. So I don't think it's all bad news, but I think we need to really take seriously where we are right now at this moment in time.

Dr. Caroline Gérin-Lajoie: Is there one story in particular that you heard from physicians or that you witnessed firsthand that really stands out for you?

Dr. Katharine Smart: Well, I think what's resonated with me this year from various conversations with many different doctors is really the story of primary care and the experience of family doctors trying so hard to keep that very essential part of our healthcare system afloat.

So I think what I've heard is so many of the same themes and the same story from different doctors. So they're all living that same reality. And I think that reality is really struggling to be able to deliver care to patients inside of a system that's not modernized, doesn't support their wellness, continues to download systems failures onto them as individuals. And I think in that milieu what's starting to happen is people are really starting to walk away from that type of medicine, and we're seeing that acutely. That really worries me because we know family medicine and longitudinal care is so essential for health. We know it's one of our best investments in terms of the system. We know it pays amazing returns on all the things the system never sees because it's working. And the fact that's really, I think, starting to fall apart and that physicians that chose that type of medicine are clearly community minded, they're people that value relational care and that they're feeling that they can no longer do that, I think really speaks to just how desperate things are in that aspect of our system.

Dr. Caroline Gérin-Lajoie: When it comes to wellness, what's the most worrisome sign that healthcare workers are struggling?

Dr. Katharine Smart: I think for me what's so worrisome is how much we are seeing so many healthcare professionals speak out publicly. And I say that's worrisome just because traditionally I think we try to shield our patients from the system's failures. When we're working in an understaffed environment or we're struggling to get a medevac or we're struggling to get a referral or diagnostic imaging, but we generally try to manage that in the background and do the best we can for our patient, but maybe not bring them in directly to our fears or worries because we want to shield them from that.

I think right now the fact that so many physicians are feeling so desperate about the system that they're speaking out so publicly is really a change and a shift from what we tended to do culturally in medicine in the past. Now, I think that's a good thing because I think we need attention on this issue, but I think the fact that so many people are feeling the need to reach out publicly to try to generate that support from citizens really just speaks to how concerned they are. And like I said before, I think it is just a real shift from traditionally how we conduct ourselves. So I think again, that should really be a sign to our leaders of just how dire things are in the system.

Dr. Caroline Gérin-Lajoie: Do you get a sense that patients and families have a better understanding of what physicians are experiencing these days?

Dr. Katharine Smart: I think we've done a good job of raising more awareness around that issue, for sure. And I think that's why it's important that we talk about wellness and talk about burnout and moral injury as a determinant, really, of the quality of care in our system. Because, again, I think the risk of hiding our own challenges from the patients and the public is that it doesn't lead us to the right conversations. And as you and I know, burnout is a risk for poor care, it's a risk for escalating costs, it's a risk for patient safety. So it's really an issue that affects all of us, not just the individuals impacted by it.

I think the more that we can bring people into our world to have them understand what we're going through, why it matters, why it should matter to them, I think it allows us to bring these issues of wellness systems types issues, and burnout into one of the things that we need to be talking about when we're talking about transforming our system. Because I think if at the center of health systems transformation is not an environment that supports wellness for the healthcare professionals in it, were never going to have a high performing system.

Dr. Caroline Gérin-Lajoie: You have warned politicians and the public that the Canadian healthcare system is collapsing. What are the signs of this?

Dr. Katharine Smart: When I chose that word, what I really meant was that we are starting to see Canadians not be able to access basic healthcare. And I could see that was starting to happen around the country. And unfortunately, since that narrative started in June it's only gotten worse. And I think right now, so many Canadians are not getting reasonable access to care and it's happening throughout the system starting in people's homes. We're hearing more and more stories, someone's fallen down and hurt themselves, an elder with a broken hip, someone having an emergency and they're waiting 9, 10 hours for an ambulance. So we've had people die waiting for ambulances. I mean, this is unbelievable. Then we've got the primary care issue where so many people, one in five Canadians don't have access to a family doctor. Again, we have our elders taking out ads in a newspaper to get prescription renewals. I mean, this is basic healthcare that people are not accessing.

The emergency department closures that have been escalating over the course of the summer here, this is really unprecedented and it's not only happening in rural areas, it's even happening in major centers. Just the number of people that are speaking out saying our emergency departments are not functioning. We've got people waiting 20 hours. We've had people dying on gurneys in the hallway. We've had people dying waiting to be assessed in emergency departments. I mean, this is extremely serious. And then we know that one of the big reasons why emerges are struggling is because hospitals remain over full. We know we have one of the lowest numbers of hospital beds per capita of similar countries. And right now, again, we've got more people in beds that don't need to be hospitalized. Again, elders who should be cared for in long term care or home care and who would prefer care in that setting are in our hospitals. That's preventing us from being able to move admitted patients from the emergency department into the hospital and that's directly contributing to the overload.

So really what you can see is when you think of the health system as a circle and all those different aspects of care that relate to each other, none of them are working. And as a result, people aren't getting care and we're having some really serious outcomes because of that.

Dr. Caroline Gérin-Lajoie: As an additional factor, what part has COVID-19 played in sparking that current healthcare crisis?

Dr. Katharine Smart: Yeah, I think COVID-19 has really been an accelerator of where we were already going. Well, I think that's a really common and important question that people ask is, are we here because we were headed here anyway or is this all from the pandemic? I think what we know is we were on this track. A lot of these things we're talking about they're not new ideas, they're not new challenges, they've been around for decades. But it's the intensity of it, the scope and scale of it, that's different. I think COVID pushed us here.

Right now, I think even though we're seeing a lot less dialogue about COVID and we've obviously completely relaxed public health measures, there is still a high number of people with COVID and those include healthcare workers. So people being off sick because they're unwell is another thing that's impacting our staffing. So I think those pressures are still there. It's still having an impact. But I think COVID-19, each progressive wave really continues to lay bare the vulnerabilities in our system. And it worries me heading into the fall in terms of how we're going to be able to rally if we see another wave with more people requiring hospitalization. And again, of course, all the other seasonal viruses that are returning as well.

Dr. Caroline Gérin-Lajoie: On this podcast, we've spoken to physicians who have been bullied and harassed, both at work and in their personal lives. As a high profile and outspoken medical advocate what has been your experience Katharine?

Dr. Katharine Smart: Well, I've definitely experienced that as well, and it was interesting and that's certainly not something I'd ever experienced before taking on the role of CMA president. I think, especially at the beginning of my term, when there was a lot of conversations around vaccine mandates, vaccine passports, and then of course, the vaccines themselves, including I was very vocal around the pediatric vaccine, being a pediatrician. I received a lot of threats and really negative comments related to that. And that took many form, it took the form of people making general threatening comments to me publicly on Twitter and then also a lot of direct messages directed to me privately through social media, calling me names, threatening me, saying horrible things. And that was, I think, quite disconcerting. Of course a lot of it is you don't know who these people are, but it's obviously not a nice feeling to wake up to all these horrible comments about you and to have people saying these really negative things.

But after a while, I just realized that was kind of part of where we find ourselves right now and I started to get better at using tools on social media, like blocking people so that you didn't have to entertain that negativity. And that helped, I think many of us that were vocal in the public really engaged in advocacy and trying to educate the public, particularly around vaccines and calling for things like vaccine passports and mandates were really at bore the brunt of that. But that I think is unfortunately part of what we had to go through to try to get that messaging out to the public.

But I think also important to know is I also received a lot of support and I continue to receive a lot of public support on social media to this day, both from the public and colleagues. And that is really nice because that sort of helps counteract the negativity. So, I think it's like many things in life. You try to focus on the positive and the impact that you're having. And every time someone would message me saying I got my child vaccinated because I heard what you said, it felt worth it to me.

Dr. Caroline Gérin-Lajoie: So in the times when this kind of issue was having a more negative impact on how you felt or on your wellness, what ways did you take to take care of yourself?

Dr. Katharine Smart: I think that's really important. And for me, how I take care of myself really involves many things. I'm a talker, so I really like to vent things out with close friends and family, and that's really helpful. And again, with colleagues I think many of us having a shared experience, just talking about it and hearing from people, what they were going through is also really helpful. I also, again, turned to try to focus on the positives and that was what was nice about having people reach out and say that your advocacy mattered to them or that they found what you had to say was informative and being able to use a platform like being the CMA president to try to do good for the public and see the rewards from that I think really helped. Because I think when you can stay focused on your purpose, it's easier to be less distracted by the negative aspects. When you can see that there's positive things happening because of the work you're doing, it really helps, I think, ground you in that and I found that was really helpful.

The other thing that for me is helpful is exercise. I always have found that when you're feeling frustrated or you've had a bad moment and you can go get a good sweat on, that sort of helps with the feelings. So I found that was helpful as well. So yeah, I think all of those things, but I think like most things in life it's really a matter of perspective.

Dr. Caroline Gérin-Lajoie: Can you talk a little bit more about what you touched on a bit in the meaning of work?

Dr. Katharine Smart: For me I often think that so much of life is like thinking about your purpose. I have this quote that I really like that I often come back to you when things are hard or I'm just having to think about my, why, which I think is important for all of us. And the quote is that the purpose of life is not to be happy, it is to be useful, to be honorable, to be compassionate, to have it make some difference that you have lived and lived well. So, I often reflect on that. So for me personally I think in my life so much of my sense of happiness has come from when I feel like I'm fulfilling my purpose. And I feel very fortunate to be a physician because I think there is so much purpose in our work and we have so much opportunity to help others and use our power and privilege in that way.

So I often find when I'm feeling less optimistic about the future or something hard is happening, I kind of come back to that and I like to think about the people that I've been able to help and the positive feedback I've had from patients and colleagues and the fact you get to just show up for people every day. And then of course, as the CMA president I've been really fortunate to have, have this platform to really try to show up for the whole country and just how lucky I am to have had those opportunities. I think when you can kind of feel that sense of purpose for me it really is a nice antidote to the harder moments. So I feel grateful to have work that is meaningful.

Dr. Caroline Gérin-Lajoie: We've also explored the issue of moral distress on Sound Mind. What have you heard from physicians about the impact of not being able to properly care for their patients?

Dr. Katharine Smart: I think that's such an important question. And again, I think it's really comes down to that issue of what is burnout and what is moral injury. And I think not being able to provide care to your patients really pushes people from burnout to moral injury because it's really that sense of you are failing and that it's really forcing you to confront your values and feeling like you are compromised personally, professionally, ethically. And I think that's really what drives that feeling of moral injury.

I think for a lot of physicians, it's really like accumulative trauma that they're experiencing is they repetitively enter this system that doesn't allow them to easily do what they need to do to care for people. And they come back to this trauma day in day out as they're trying to navigate this system for their patients. And then on the other side of it they're being told by leaders that everything's okay, the issues are being minimized or they're being downloaded them onto them as individuals, like you need to solve for this, or you need to work harder, you need to be more resilient. When really, they're already doing all those things.

I think that's what I'm really hearing right now from people, that's, I think, where the distress really comes from is that sense of, well, how do I navigate this? How do I move through this traumatic experience? And how do I make sense of what I'm being asked to do in this system that's so fundamentally flawed? And I think that can sometimes drive the hopelessness that people are feeling. I think, again, that's why it's just so important that we address this issue because what's so clear to me is we are so fortunate in Canada to have really incredible healthcare professionals, physicians, other healthcare professionals. We're well trained. We're a very caring group of people. We have excellent folks in the system, but we are destroying those people. We're tearing them apart by a system that's so broken. And that is really deeply worrisome because we all know the health system is the people in it. And if we aren't designing a system that allows folks to thrive there and to be healthy, to be well themselves, we're never going to be able to give people the quality of care that they deserve. I think when we can't give people high quality care, again, it just drives that sense of distress. So I think these things are really all related.

I'm really glad that we're elevating the conversation around burnout to these systems pieces. I think that resonates much more with physicians and I think when we have those types of conversations, they're like, yeah, that makes sense. That's what's happening to me. And then I think that also fuels your sense of, okay, then that gives me something I can do, maybe I'm going to become a leader or I can speak out or I can do something about the system that I'm in or at least be at the table. And you can start to feel like you can take a bit of that control back and I think that can be helpful too.

Dr. Caroline Gérin-Lajoie: Another issue that's reflected in the National Physician Health Survey and that has come up on the podcast is how the administrative burden linked to EMRs can really have a negative impact on wellness. Is this something that surprises you Katharine?

Dr. Katharine Smart: No, not at all, because that's certainly been my experience as a physician. And again, hearing more and more about that from colleagues. I think the administrative burden piece is massive. I think all of us as physicians chose medicine because we like being around people, right? It's a people job. And whether it's our patients or our colleagues, it's a human profession. And I think that administrative piece often takes us and our time away from those direct interactions. So it's not very fulfilling. Of course, it's often unpaid. So it's again, making people spend a lot of their personal time doing something that they're not getting any joy or meaning from. And a lot of it is meaningless. It's just filling out a form for the sake of a form or it's a sick note that really they didn't need or it's rewriting a referral because someone wants it on a specific piece of paper, even though all that information they're asking for was already in the letter you sent. It's the EMR that doesn't work well that you're spending all this time trying to navigate.

So all of these things are just frustrating. Most of them don't add value for the patient. And I don't think anyone would say they find joy in the administrative work of medicine. So I think that's of course been the unintended consequences of electronic medical records and I think of an increasingly bureaucratic system is that a lot of this is being downloaded onto physicians and it's not adding any value to their time or to their day.

Dr. Caroline Gérin-Lajoie: As CMA president you spent a lot of time advocating for solutions to health workforce shortage in the huge physical and mental fallout. What are some solutions that would support healthcare workers both in the short term, but also in the long term?

Dr. Katharine Smart: Well, I think many of the solutions honestly lie in addressing the root causes of what's not working in our system. I think we've been talking about integrated team based care for a long time and I honestly think that is the answer for many of these issues. Again, when you're on a team you derive meaning in that you have people supporting you, you have the ability to share the burden not just on yourself, people there to back you up, support you. For patients it means they're getting the right practitioner for their problems at the right time and they're not just reliant on one individual to be present for them all the time, which is just not a sustainable expectation.

So, I think if we can really start thinking differently about how we organize ourselves in healthcare, embracing the broader scope of practice of other health professionals to work with us and support us in our work, move beyond that sense of we're all individuals to, hey, how do we form together as teams? I think that's going to really help. I think there's also some great examples of other places that are using health professionals like medical assistants to help with things like the administrative burden. There's examples in the United States and Virginia Mason Institute, they have medical scribes or medical assistance, as they call it, that are paired with every physician. So as you move through your day caring for your patients that person's at your elbow supporting you, making sure the notes are done, the forms are filled out, the referrals are made, the surgeries are booked. So when you come to the end of the day, your work's actually done.

So those things like that, where you think, well, why aren't we doing that? It's a better use of your time as the doctor, the patient's care is going to be more comprehensive because you're not distracted by doing those things. And again, we're giving people back time, which is so valuable. So I think there's ways of re-imagining the way we work that would really make a huge difference. I think at the root is really this idea of these integrated teams and moving past this notion that individuals can be responsible for healthcare on their own. I just don't think given the complexity of our population and aging population, increasing concerns with mental health in our population, that's realistic. And I think if we could start to see people's time as value and their time as wellness and their experience as wellness and we build the system around that prioritizing the patient experience and the provider experience I think we get a lot closer to something that's going to work and be sustainable.

Dr. Caroline Gérin-Lajoie: Any reflections on what's missing for us to be able to actually get to those solutions?

Dr. Katharine Smart: Well, I think the biggest problem we have is our model of care that's so antiquated. I think the fact that this idea of public health care largely went down the road of private business model is fundamentally flawed. We know that most physicians work fee for service and it is really essentially a public private partnership where they then fund their private infrastructure of that community based care from those billings. So that I think worked back in the day when people were less complex and of course the costs of doing that were different.

But now what's happened with, I think the complexity of patients changing, the aging population, and of course the infrastructure costs having dramatically increased the rent, what you have to pay people to work and support you in your clinic, the costs of EMRs, internet, all those things have exponentially increased. Those two things have just outpaced each other. So now we have this model that just isn't really economically viable. And then when you think about trying to bring team members into that type of a model, well, who pays for those team members, right? So, I think what we've done is we started with a model where physicians really bore the majority of the infrastructure costs of community care and that's just not working anymore given the state of our country and people's health. And it really doesn't allow innovation in terms of bringing other people into the team because there's no source of payment for those people to support that resource.

So, I think that's where we need to, again, rethink like whose responsibility is it to provide the infrastructure for care if we believe that these team based care is the future, and I think many people think that. Then whose job is it to resource that for the public. And I think that needs to be a partnership with the government, they need to be supporting that. And I think we as physicians need to be opened to different ways of working so that we can actually make sure that everyone's getting care. But I think we really started out with this very siloed lens on healthcare and I just don't think it's serving us anymore and I think we have to let go of that and we have to be willing to organize ourselves in different ways, both for our own benefit and for the benefit of the patients.

Dr. Caroline Gérin-Lajoie: As you finish your term as CMA president, how optimistic are you about the future of healthcare in Canada?

Dr. Katharine Smart: Well, I feel we have no choice, but to be optimistic because the healthcare system is so important. There's no question that all of us are going to interact with the healthcare system at some point. Whether it's for ourselves personally, someone we love or someone we care about, health is essential and it's essential to our country's function. You can't have a good economy without a healthy population. So healthcare I think is so important. I think it's highly valued by Canadians. We know it's part of our identity, it's something we're proud of. And I'm proud to be part of our healthcare system, because again, the people that I know that are in the system are amazing. And even though the system itself broadly is struggling, I know that the individuals who compose the system are exceptional and they're there and they're showing up and they want to make it better. So I believe it's possible. I just can't believe that the alternative it's got to get better.

I hope that because we find ourselves where we are today, where it really is at a crisis level, but we have been able, I think, to really inform the public of that, bring attention to the issue, leverage some of these things like social media to get our messaging out there, that more and more people are seeing the necessity of really taking action this time, like taking it seriously. So I hope we leverage this moment. I think we know when you look through history, things like pandemics have always brought about major political, social, cultural change. I think there's an opportunity here for that in terms of the healthcare system. There's never, I don't think, been a more pressing moment to really get down to what needs to happen to make things better. I think we have the knowledge, the expertise, and now I think a common vision and goal about where we're headed across healthcare professionals to make that happen.

So I believe it's going to get better. I don't think it's going to be an easier straight road to that outcome, but I think we've got to start heading in that direction and I hope that the CMA will continue to be part of that change.

Dr. Caroline Gérin-Lajoie: And now that you've had a year of talking to physicians all across Canada, you have any final thoughts around the importance of physician wellness?

Dr. Katharine Smart: I think physician wellness is essential to the transformation that needs to happen in our system. And I think the more that we pay attention to ourselves, what we need, how we need to be healthy to show up for our patients and for each other as colleagues, the better and stronger and more resilient our system's going to be. I think our wellness is linked directly to the system and I think the more we can show that leadership and be part of driving the change in the system as physician leaders, I think the more we can do to ensure the wellness of each other and our colleagues and everyone else in the system. So, I think it's a fundamental building block to what needs to come. I'm really grateful that it's something we're thinking more about. Because when I started this journey as a physician, it wasn't really something that we talked much about over 20 years ago and I've had to unlearn and relearn a lot of my own ideas around that. But I think we're headed in the right direction there too. I think it's only going to pay dividends for future physicians that we start to really pay attention to what we need to show up is our best selves.

Dr. Caroline Gérin-Lajoie: Thanks so much for joining us. Dr. Katharine Smart is now the past president of the Canadian Medical Association. She's also a pediatrician based in White Horse.

And that's it for season two of Sound Mind. The podcast is taking a break in the coming months. If you are new to the podcast, I recommend going back and listening to past episodes. We've covered a lot of ground on physician wellness and have heard some really powerful stories. I'm Dr. Caroline Gérin-Lajoie, please share, recommend rate and review this podcast, it will help others to find it. Thanks so much for listening.

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