As the medical community continues to adapt to seismic change, signs of respite and relief remain elusive. The 2021 National Physician Health Survey (NPHS) conducted by the Canadian Medical Association (CMA) reveals the dire state of physician health and well-being in Canada today and provides a look at what’s to come.
Results from the survey indicate that practising physicians and residents are experiencing nearly double (1.7 times) the level of burnout compared with participants in the 2017 NPHS. Key drivers of physician burnout include fatigue (the strongest factor), low professional fulfillment, dissatisfaction with their current job, feeling moral distress, experiencing bullying and harassment in the workplace, a lack of social support, poor or marginal control over their workload, dissatisfaction with work–life integration and an excessive or moderately high amount of time spent on electronic medical records (EMR) at home.
In a series of profiles, the CMA shares the perspectives and lived experiences of Canadians to help amplify the concerning discoveries reported in the 2021 NPHS.
This article profiles Dr. Laura Sang, a family physician in the greater Montreal area. Her experiences as a new family physician offer a powerful view into what it means to be in the midst of upheaval in the medical community, particularly when serving resource-strapped communities.
Dr. Sang shares how she navigated transitioning from residency to practice and what the knock-on effects of colleagues quitting mean for primary care providers and their patients.
Sacrifice and self-care during the most challenging times
Dr. Sang was born and raised in Montreal and chose to set up her practice in the nearby Laurentians so that she could still access the city while meeting significant patient needs outside of it. She is building her private practice while also working at a rehabilitation centre and covering a maternity leave in Côte-des-Neiges, Montreal. Juggling a hat trick of responsibilities isn’t unusual for physicians today as they shoulder the burden of trying to address overwhelming patient demand.
“Before the pandemic, things already weren’t great,” explains Dr. Sang. “Whether it was for immediate care in an ER or waiting for a referral to specialists, there has been a constant pressure for family physicians to help fill system-wide gaps in care. When I was working in rural areas, this was even more noticeable.”
She shares that while she was on a residency rotation in a remote rural area, the doctors found that certain autoimmune diseases were prevalent in that community. “The doctors took it upon themselves to learn first-, second- and third-line management to support patients while they waited for a rheumatologist. Filling this gap meant patients didn’t have to wait to start treatment until a referral eventually came through.”
This type of Band-Aid bridging was already stretching family doctors. When the COVID-19 pandemic emerged in March 2020, it quickly became clear that a stressed health care system wouldn’t bend — it would break.
A spiralling system often puts physicians in untenable positions of deciding between helping or adhering to standard processes of care. “For example, prior to COVID, a physician would never work up chest pain as a phone consult but when you have a patient who is elderly, frail and severely immunosuppressed, sending them to the ER to wait for hours and potentially catch COVID is something that gets added into the equation. And it adds to an already cumbersome documentation process by including the medicolegal justification for not approaching health issues ‘by the book.’"
Add to that the traumatic effects of lockdowns and quarantines, and the expectations for physicians to become superhuman. “The first wave was the hardest for me because it was just this massive unknown,” shares Dr. Sang. The complete lockdown and separation from social support systems made fighting the coronavirus feel bleak.
“We didn’t know if we were going to die from it or not,” she says bluntly.
“I just wanted a hug so badly. I hadn’t seen a friend or family member in over three months at one point and the only physical contact I had was when I contracted COVID-19 and had to get an IV put in,” she describes. “I remember lying in the emergency room and being like, ‘Ok, we don’t know what this is, and we don’t know what it’s doing to me, so I’m either going to improve and go up to the ward, or I’ll need to be intubated in about four hours and transferred to the ICU.’”
Caring for patients at the expense of their own well-being pushed many physicians to the brink, especially when they were confronted with abusive situations like harassment or physical assault.
“We went from rationing masks and being applauded to having anti-vaxxers and deniers end up in intensive care refusing treatment,” she explains. “To have to go back and treat COVID patients, quite literally in the same room you once thought you were going to die in, was absolutely brutal. I can’t even tell you what it did to my mental health — I had to take a leave of absence from my residency.”
For Dr. Sang, the crash and burn necessitated taking time off. Recovering from COVID-19 herself and processing the trauma and burnout sidelined her; she returned to practice with stricter boundaries in mind. Unfortunately, some physicians have not been able to bounce back from the profound level of burnout, with many leaving the field altogether. Others plan to reduce their clinical hours to counterbalance the fact that they simply cannot do it all.
The idea of self-care can feel inaccessible, if not ridiculous, while physicians are functioning in an unending crisis mode. “Self-care became equated to self-preservation,” explains Dr. Sang. “It wasn't about keeping myself well; it was about surviving. It’s like how you wouldn’t talk about or expect ‘self-care’ in a war zone with bombs going off left and right. Being encouraged to take deep breaths and reach for gratitude is just insulting.”
“It’s not over for us.”
As the health care system endured wave after wave over the past three years, it has left an indelible question about what it means to be a physician today. The 2021 NPHS reports that 79% of physicians rated their professional fulfillment as being low. Paired with the realities of burnout, it shouldn’t be a shock that more than half of physicians and residents indicated a desire to modify or reduce their clinical hours in the next 24 months.
For Dr. Sang, she describes a need to find herself again while processing the trauma of her pandemic experience.
“I don’t think I’ve fully reconciled things because this is not over,” she starts. “And while we’ve gone back to a semblance of ‘normal’ in the community at large, it’s definitely not over for us.” With the worsening backlog and congestion in the health care system, Dr. Sang observes that the patients who are coming in to see her now are sicker than they would have been before March 2020.
She describes the shock of witnessing established colleagues with 30 or 40 years of practice burning out or having to leave altogether. As a new graduate, it was deeply concerning.
“As a new doctor, I feel some rage that these are the same issues I remember my parents talking about when I was a kid — the wait times, the lack of centralized care. Both mental health- and physical health-wise, I’m seeing people who are much sicker because of delayed care and increasing comorbidities,” she says. “It’s so much harder to play catch-up and then try to deal with cases that are increasingly complex, especially when we have next to no support in handling this.”
The ramifications include widespread physician and health human resource shortages, ER closures and, ultimately, an inability to provide care.
“The situation is dire; people are desperate,” she says frankly. “Yet the system and government knew that, at some point, all these people would start needing more care. That the baby boomers would start needing more support as this population group ages. But no one did anything to prepare for this, so we have nothing for them.”
Dr. Sang chose to establish her career in this part of Quebec because she could serve pressing patient needs while also maintaining her wellness with access to nature and hiking. The need for physicians to design a career in which they can protect their wellness intensely is indicative of a system that breeds unwellness.
“With multiple doctors retiring, there are thousands of patients without a family doctor,” she explains. “Here, they had at least 20 vacancies for family doctors, while other areas only had one or two spots open. I saw this as my biggest opportunity to help the most people. And I can maintain a slower pace of life surrounded by nature. It’s sort of a happy medium so that I can maintain my wellness.”
However, if she wears any sort of clothing that reveals she’s in medicine while out hiking, she gets stopped with inquiries about taking on new patients. Going incognito on the trails is essential to maintaining boundaries and attempting normalcy.
Repairing patient trust with an unrepaired system
With so many physicians across the country expressing intentions to reduce their clinical hours over the next 24 months, the added stress on an already over-extended workforce stands to unravel the health care system even further.
“I can't think of a single person who didn't consider quitting or decreasing their hours at some point just because of how frustrating and emotionally, physically and mentally exhausting it is to deal with our system,” says Dr. Sang. “Working in our health care system sometimes feels like trying to live with a toddler who is throwing a tantrum 24/7. The hoops we have to jump through are beyond burdensome and inefficient.”
As physicians reduce their hours or quit because of burnout, their colleagues must address the overflow of patients and stop-gap measures have to be put in place. “If they don’t have a family doctor, patients rely on walk-in clinics. Or they end up in the ER for things that are not emergencies — things that don’t need already scarce hospital resources,” she says.
In addition to struggling to find care, patients lose trust in the system. “I’ve seen patients cry when their family doctor retires because that individual was a huge support throughout their life,” she admits. “This is especially difficult for marginalized groups such as Indigenous people and members of the LGBTQ+ community who experience significantly higher challenges in getting adequate care. A trusted family doctor can make all the difference.”
With family physicians burning the midnight oil chasing test results, resubmitting referrals and juggling administrative loads like EMRs and billing, commentary about their work ethic is particularly offensive. These are just some of the key drivers of burnout identified in the CMA 2021 NPHS regression analyses, which can serve as warning flags for leaders and administrators to tune in to the state of physician wellness and the health care system.
“I think there's a lot of anger and resentment toward the government when there’s messaging framed, like, that doctors don't work hard enough or that we need to take on more patients,” says Dr. Sang. “It’s shocking. And this makes it very clear that these folks don’t even understand what our lives are like trying to hold things together on the front lines.”
The NPHS spotlights the harsh reality of practising medicine today and what residents and physicians will continue to face in the years ahead. The long-lasting consequences of the last three years for the medical community remain inadequately addressed despite more waves and continued shortages.
“What was coming 10 years from now just got sped up by the pandemic,” says Dr. Sang. “I describe it like faulty plumbing — our health care system is like a tap with steady flow into a narrow drain. COVID not only opened that tap all the way by adding increased health care needs, but it also put a stopper in the drain leaving nowhere for the water to go.”
She hopes that the government and health care stakeholders can look at broader population health and help move providers out of a crisis care state. “If the general population has access to things like financial resources, dental coverage, mental health support and food security, they will be less likely to utilize health care resources as urgently,” she says. “But we also need to take care of the providers and ensure adequate compensation and reasonable hours for physicians, nurses and other allied professionals. Otherwise, we’ll just keep burning out, and at some point, you will simply hit your limit.”
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