Physician wellness has come to the forefront of the medical community, particularly through the unprecedented strain of the COVID-19 pandemic. For physicians and medical learners serving disadvantaged and vulnerable populations, that stress is compounded even further by the pressing needs of their patients.
In this article, three leaders in the health care community share their perspectives on burnout among Indigenous physicians and medical learners.
The Pandemic Dissolved Any and All Health Boundaries
In the CMA’s recent National Physician Health Survey, more than half of 4,000 participating physicians indicated high levels of burnout – up from 30% in a similar study from 2017.
Indigenous physicians face additional challenges in taking care of themselves and the communities they serve.
“When people would come into the hospital for surgery, I used to have a mix of people who were healthy and sick,'' explains Dr. Alika Lafontaine, the first Indigenous president-elect of the Canadian Medical Association.
“Especially during the peaks of the pandemic, everyone is very sick. There’s a heaviness that comes with dealing with an unrelenting flow of critically ill patients. It’s not normal for physicians and learners to be witnessing preventable death and disability at this scale,” he says.
Dr. Lafontaine has also observed the downstream effects of the pandemic, like the cancellation of surgeries, limitations to accessing care, and mistrust of or hostility toward health care workers.
“A lack of access to care is, unfortunately, pretty normalized in Indigenous health systems. That leads to sicker patients because of later presentation for care,” Dr. Lafontaine says of the pandemic’s ability to magnify existing health care disparities.
It’s a magnification that doesn’t affect only patients.
“For health care workers, even if every wave of the pandemic we face had the same level of intensity, subsequent waves felt worse because didn’t have the space to recover and get back to what used to be normal workload,” says Dr. Lafontaine. “People can’t keep up mentally, emotionally, or physically. Layer that on top of what Indigenous physicians were going through pre-pandemic, such as scarce resources and high workload – it’s especially harsh. When our health systems broke, a lot of our workforce broke as well. We talk about rebuilding, but we’re still at risk of the damage getting worse.”
Dr. Cornelia (Nel) Wieman has experienced a similar depletion. Dr. Wieman is acting deputy chief medical officer (A/DCMO) at First Nations Health Authority, which serves all 203 of British Columbia’s First Nations communities.
“Working virtually in public health has meant a complete blurring of the lines between home and work,” she explains. “I’m rolling out of bed at five in the morning, sitting on Zoom calls and working through evenings and weekends.”
Dr. Wieman says that the need to advocate for Indigenous communities during the pandemic has been constant and urgent. “I have never worked as hard in my entire life as I have in the last year and a half,” she says of the increased demand on Indigenous leaders like herself.
Additional Layers of Trauma and Emotional Labour
In May, 2021, 215 pairs of tiny shoes were displayed on the steps of the Vancouver Art Gallery – one for each grave discovered on the site of a former residential school in Kamloops. Since then, burial sites have been identified across the country.
The weight of witnessing these tragedies, as well as educating others in the health system about them, tends to fall on the shoulders of Indigenous physicians and medical learners.
“There's a mental toll that the unmarked graves have had that I don’t think our non-Indigenous colleagues really understand the gravity of,'' explains Dr. Wieman. “Many, many Indigenous physicians are affected by residential schools intergenerationally. They have direct experience, or their parents or grandparents were residential school attendees.” Dr. Wieman, a survivor of the Sixties Scoop, recalls her early years vividly.
“Neither of my adoptive parents had gone past grade eight. So, I didn't have that experience of going through medical training in my family or even university,” she says of the importance of Indigenous representation in education and health care.
As the awareness and discourse around anti-Indigenous racism in Canada grows, Dr. Wieman emphasizes that cultural safety or equity, diversity and inclusion (EDI) initiatives must go beyond Indigenous physicians stepping up or volunteering. “I think all Indigenous physicians end up getting asked to do this, be a part of that, join this board. But it’s almost always unpaid and it is extremely taxing,” she explains.
This representation gap is a friction point that affects and inspires future physicians like Santanna Hernandez, president of the Canadian Federation of Medical Students.
“I had a lot of really traumatic experiences accessing health care and watching how my family had to navigate the health care system,” shares Hernandez, who is also a mother of four.
She recounts how, to be treated adequately in the health care system, she would carefully get dressed in her best clothes to see a doctor. And how she had to teach her white husband about advocating for her and their children during childbirth and in the hospital.
“I was 14 the first time I had a health care professional pull my Pharmacare file to prove I wasn't drug-seeking,” she remembers of a hospital visit resulting from a car accident that left her with a fractured spine.
“They didn't want to provide me with pain medication because of what they assumed about me and about my background. As if I could make up the excruciating pain of a spinal fracture,” she marvels. But it’s this lived experience of learning to navigate the health care system that inspired Hernandez to consider medical school as a mature student.
“I can't remember a high school counsellor, or anyone, actually, saying that I could do something like becoming a doctor,” she says. “The only thing the counsellors or teachers would say to us was just to not get pregnant before graduation, So, I never even had the encouragement to try and go to college, let alone med school.”
Setting and Respecting Limits
As Hernandez pursued her path to medical school, she quickly realized that not all student struggles look alike. For example, many Indigenous medical learners were left disadvantaged when the COVID-19 pandemic pushed the world into lockdown. “Some smaller communities don’t have cell phone coverage or WiFi. I’ve had to drive into town to sit in a Tim Horton’s parking lot to do work, and I’ve heard many students having to do most of their med school in their school parking lot so they could get stable Internet.”
It’s a struggle echoed by Dr. Wieman, who recalls periods in medical school when her mentor would provide her with groceries because she didn’t have enough money to eat. “You know, I spent about 30% of my time back then just worrying about my survival. Like, covering my food and my rent,” she remembers. Dr. Wieman explains that these are concerns that mainstream or non-Indigenous medical students generally don't have to worry about or experience.
Her mentor would periodically take her to the local farmer’s market on Saturday mornings to ensure she had enough food stocked in her fridge to keep her going. The inherently disproportionate power dynamics in medicine are so pronounced that informal mentorships like this one are a critical aspect of fostering the emotional well-being of Indigenous learners.
This type of lived experience is helping to inform the creation of a national mentorship program through the Indigenous Physicians Association of Canada (IPAC), where Dr. Wieman is president of the board. The program, which received a $1 million donation from the CMA Foundation this year, aims to formalize mentorship in a way that will create more space and opportunities for both mentor and mentee to flourish.
“The burnout that we see among our few Indigenous mentors, even at well-connected medical institutions, can be disheartening,” says Hernandez of the drain faced by her role models. “Medical learners want and need their mentorship and support, but we also see the weight they carry and don’t want to be an added burden.”
Through learning from and witnessing the expectations placed upon today’s Indigenous physicians, it is hoped that medical learners and future leaders will be better able to navigate the field with knowledge hard-earned by their predecessors.
“I had to learn the hard way,” Dr. Wieman confesses. “I have gotten myself into some real difficulties over the years — taking too much on, getting involved in too many things, not setting limits or saying no.”
In fighting to get a seat at the table, to represent and advocate for their communities, many Indigenous physicians have had to do so at the expense of their health and well-being.
Moving into the Future of Medicine
As physicians continue to experience burnout and face hostility as consequences of the ongoing pandemic, Dr. Lafontaine believes this experience may lead to the reinvention of the system as a whole.
“The core of the question around burnout nowadays is whose lives are we going to save? Because we're now at a point where we can't save both — we can’t save ourselves, and we can’t save our patients. So, the system needs to change in a meaningful way,” he explains.
“The well-being of our patients and us as physicians depends on it.”
For the first time, the CMA’s 2021 National Physician Health Survey (NPHS) invited respondents to self-identify as Indigenous, to better understand the specific challenges faced by this group of physicians and to inform future efforts to support them. The CMA will be releasing data and findings from the 2021 NPHS in 2022.
If you are part of the Indigenous community and are experiencing pain or distress as a result of a residential school experience, the Indian Residential School Survivors Society offers a 24-hour crisis line supporting individuals and families. Please call 1-800-721-0066.
If you are a physician or medical learner who is struggling, contact your local physician health program.
Are you in distress? Get help now.