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Sound Mind: The personal cost of leading Canada’s public health response to COVID-19

November 24, 2021 CMA

For most physicians, the fight against COVID-19 took place away from public scrutiny. But for public health physicians, their words, their work, and sometimes their raw emotions, have taken centre stage. Two of Canada’s chief medical officers of health – Dr. Saqib Shahab from Saskatchewan and Dr. Catherine Elliott from the Yukon – share the toll the pandemic has taken on them and their colleagues.

“It was only a few months in where I thought, no human can really keep this pace: new evidence coming in every day and all of us trying to stay on top of it and give the best advice; the pace of meetings and press conferences, and evidence-based decisions, and the weight of these types of decisions.” – Dr. Catherine Elliott

In this episode, host Dr. Caroline Gérin‑Lajoie speaks with Dr. Elliott about what causes moral distress among public health physicians and recent survey results from the Public Health Physicians of Canada showing high rates of burnout among its members.

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.

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The personal cost of leading Canada’s public health response to COVID-19

Dr. Caroline Gerin-Lajoie: Welcome to season two of Sound Mind, a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gerin-Lajoie. We've discussed on this podcast the tremendous impact COVID-19 has had on physician wellness. When the global pandemic was declared in March 2020, medical professionals went into hyper-drive to treat patients and keep themselves safe. For most physicians, this work was done inside a hospital and away from the scrutiny of the general public, but that is not the case for public health physicians. Their work has been center stage throughout the pandemic, and this means the human toll of their work has also been front and center. Early in the pandemic, BC's Dr. Bonnie Henry fought back tears as she described the impact of COVID-19.

Dr. Bonnie Henry: I think this is something that I'm very concerned about. I went through SARS. I've been through Ebola. I've been through the pandemic in 2009, and I just know how stressful it is for our healthcare system, for my colleagues and for families that are dealing with this. I'm probably a little tired myself, but what can I say? It's a very difficult time and I'm feeling for the families and the people that are dealing with this right now.

Dr. Caroline Gerin-Lajoie: And earlier this fall, Saskatchewan's Chief Medical Health Officer, Dr. Saqib Shahab, struggled with his emotions as the province was entering its fourth wave. It led one reporter to ask if Dr. Shahab was okay.

Reporter: This wasn't the question I was planning on asking, but Dr. Shahab, are you okay?

Dr. Saqib Shahab: I'll take a minute, but please. I just say that all the evidence is out there, and it is very distressing to see unvaccinated, young, healthy people ending up in ICU and dying. I'm watching this from a distance, but the pressure just puts, we talked about burnout, Derek [inaudible 00:02:24] talked about burnout on staff. To see young lives lost to a vaccine-preventable disease, how can we accept this in a country where we've had vaccines available for everyone ever since July.

Dr. Caroline Gerin-Lajoie: Dr. Shahab spoke with us about what was going through his mind at that press conference.

Dr. Saqib Shahab: I think that was the sadness, that at the end of the day, these were all people we knew. Everyone knew someone who knew someone who was ill with COVID, or hospitalized, or had passed away. I think that is the sadness and the grief, and the fact that it came so late in the pandemic for us, it hit us hard. Obviously I know many friends, relatives who were in their 80's, other parts of the world, who have passed away and many colleagues who developed COVID early on in parts of the world where there was not effective PPE available. Even in Saskatchewan, it's a vast province with a small population. I, along with many of us know personally people, not working in healthcare, but in the general community, who became unwell with COVID, who became seriously ill or passed away. So everyone knows everyone. I think that has been very hard and it was hard throughout the pandemic, but at this later stage, it's even harder.

Dr. Caroline Gerin-Lajoie: Public health physicians also found themselves at the center of the battle over vaccines, and this added further stress to their role as they tried to foster unity in the fight against the virus.

Dr. Saqib Shahab: Society was getting polarized. There were people who were vaccinated and then blaming people who are unvaccinated for delaying their urgent care, and people who are unvaccinated saying, well, why should we get vaccinated, we don't know enough. I think one has to really move forward from this polarization. I think it is very much driven by social media, and one has to move forward because it has torn families apart in some cases. We have to heal and move forward as communities, in my view.

Dr. Caroline Gerin-Lajoie: Dr. Shahab says all of the stresses combined with extremely long hours began to impact the wellness of colleagues.

Dr. Saqib Shahab: Because it was very stressful for many team members. All of us responded differently. Some of us have had great supports at home, I did for example. But of course, many individuals, including colleagues and friends, had a tremendous sense of social isolation. So providing that bridge, not just as a colleague, but as a friend, as an acquaintance was critical. There's formal structures for that through mental health outreach services, but I think at a personal level, staying physically distant, but socially connected was not just a slogan. It was something that I certainly took to heart and made sure that I remained connected with people who I knew and made sure to check in on people. I think that self awareness, I think was critical.

Dr. Caroline Gerin-Lajoie: Dr. Saqib Shahab is Saskatchewan's Chief Medical Health Officer. The organization that represents public health physicians in Canada has grown increasingly concerned about burnout amongst its members. It recently conducted a survey that found that nearly all participants said they were feeling burnt out. Dr. Catherine Elliott is a member of the group's council, and she is also the acting Chief Medical Health Officer for the Yukon. Dr. Elliott, thank you for joining us.

Dr. Catherine Elliott: Thank you for having me Caroline.

Dr. Caroline Gerin-Lajoie: Is it okay if I call you Catherine?

Dr. Catherine Elliott: Yes, of course.

Dr. Caroline Gerin-Lajoie: What was your reaction when you saw or heard your colleagues, Dr. Shahab and Dr. Henry struggle to contain their emotions at various points during the pandemic?

Dr. Catherine Elliott: Well, let's start with Dr. Henry. I've known Dr. Henry for a long time. She was on the council of my residency and one of the mentors and people who examined us during residency, and I know how strong and capable she is. To see her show her emotions in a news conference, it really was a powerful moment for me. It just, to me, it showed two things. One was that the power of sharing one's emotions publicly, and that there's a place for that, and how important that can be. It also showed me how to see someone who's been through so much, so many situations, infectious disease situations, and other challenges, professional challenges, just have that moment, really gave me a sense of what could be coming and how serious and impactful the pandemic could be. That was very early on in the pandemic. I saw her conference where she cried when the first long term care patient in BC died. That was a pretty profound moment I would say for me, in terms of what could be coming.

Dr. Catherine Elliott: Dr. Shahab is somebody who I've gotten to know through meetings over the course of the pandemic. Again, a very intelligent, capable person. When I heard him on the radio, not that long ago, maybe a month or two, breaking up, I really almost felt a sense of relief because I think many of the leaders in public health at this time have seen and witnessed so many challenges among colleagues or themselves, or seeing the toll that the pandemic has taken, that it was almost a relief to have that be more public in a way.

Dr. Catherine Elliott: I thought what he said about the evidence is here and to see young, healthy adults die of a vaccine-preventable disease, for me, that just triggered so much because in my training, people died of vaccine-preventable disease mainly in places where they couldn't get vaccines. To know that's happening here in our own country was, it really struck a chord with me, and again, just brought back how profoundly impactful this pandemic has been among the population and also for our, for the leaders in public health.

Dr. Caroline Gerin-Lajoie: How difficult has it been for medical officers of health to keep the stress of their work hidden from the public when their job requires them to be the public faces of pandemic, public health guidelines?

Dr. Catherine Elliott: I don't think it's been, I wouldn't say that I have noticed it's been challenging for people to do that. I think it's part of our training almost, and it becomes inherent. I think what's hard is when everyone goes away and the camera's away, and you have that reflective time, and it can come back for a lot of people, just as a sense of knowing what is happening. Just the extremity of the measures that we've had to put into place, and some of the potential harms of those measures, and also the relentless pace of the pandemic for such a long time. I think in my training, the longest outbreaks or situations that we dealt with at this kind of intensity would be maybe three months, and I think that's the pace we started to keep from the beginning. There may have been some lulls at various times for people, but really it feels like catch up in those lulls. I think the relentless pace, and then the pressures of being a public figure can definitely take their toll.

Dr. Caroline Gerin-Lajoie: So going back to instances where a public health official may become emotional while on TV or during an interview, is that what it takes for the public to start wondering or asking if that healthcare professional is okay?

Dr. Catherine Elliott: I sometimes wonder what the public thinks when an official becomes emotional, because I don't really see those officials in the same way as the average person might in the public. I would imagine that some people appreciate their compassion and truly sympathy with what they've been through. I would also think that some people might think that their capacity, the official's capacity or ability or judgment might be somehow altered because they're fatigued or emotional. But I think we're all human and I think in both the public instances that we've talked about, you can see how well Dr. Henry and Dr. Shahab pull themselves together and get right back on point and sort of put their own feelings away, and get right back to the business of doing the job that needs to get done. I'm not sure that there's been a loss of trust because of that. In fact, I think it almost breeds more trust because people can appreciate that the recognition of the gravity of the situation, and the loss that's happened is really there and it is a part of the picture.

Dr. Caroline Gerin-Lajoie: So, Catherine, when did you first start being worried about burnout amongst your colleagues?

Dr. Catherine Elliott: I think I was [inaudible 00:11:46] very impressed with how hard working, dedicated and steady my colleagues have been. Nonetheless, it was only a few months in where I thought, no human can really keep this pace. I mean, the pace of the new evidence coming in every day and all of us trying to stay on top of it and give the best advice. The pace of meetings and press conferences, and evidence based decisions, and the weight of the types of decisions. The types of societal changes that we were imposing in order to save lives and keep the burden off the healthcare system was substantial. I think I became worried or concerned that if we kept on that track, people would burn out. That was probably early, about three months in or four months into the pandemic.

Dr. Catherine Elliott: It was only later that I learned that many of the Medical Health Officers across the country had experienced burnout and some had rotated on and off their work or taken leave. Others had health authorities had brought in, or health units had, or government's have brought in extra staff in order to staff all of the positions that needed to be staffed. It's an unbelievable cognitive and physical challenge to be working like that. I mean we've all, done it. Residency, we do call, and we have intense periods in our work, in producing guidance or deadlines or meetings that come up, but to do it in this relentless pace, without an end in sight, is something that would drive anybody to burnout.

Dr. Caroline Gerin-Lajoie: What were some of the first signs of burnout that you saw or that you, you heard of in those first few months?

Dr. Catherine Elliott: In the first few months, I honestly don't think I saw a lot outside of my closest, closest colleagues, people who I know personally or within my own work environment. I think it's because we work as professionals often, and on zoom our meetings are distant, to the time the hallway corridor chats and that were not happening as much. I really started to see it within a few months. Being concerned about people working in amongst with my colleagues with no weekends, or not taking any time off. I was concerned about the first things you get concerned about, which are things like car accidents, or painful things occurring in interpersonal relationships, that type of thing. And then also concerned about the long lasting impacts if we continued at that pace.

Dr. Catherine Elliott: It was only maybe six or twelve months in that I started to see people really coming to tears over things from time to time in meetings or in closer conversations. We actually started to have hallway conversations to phone each other after a meeting or text, which was really one of the great things about this time has been is those colleagues that you've met only over zoom. But that is really when I started to see the effects of burnout amongst colleagues. I also noticed jobs becoming vacant and people moving around, which is another sign of sort of a restlessness within the profession.

Dr. Caroline Gerin-Lajoie: Do you have any thoughts as to why it's been difficult for your colleagues to talk about burnout?

Dr. Catherine Elliott: I think one of the things as caregivers and in our profession is that we like to take care of each other as well. We wouldn't want to burden a colleague with the challenges that we are having. So I think that made it hard. There wasn't a space for it in our professional environments or meetings, even as preserving in, along the lines of preserving the medical health officer or, public health physician workforce. I didn't hear a space for it at the national table where I'm really a part of that. The focus was really and importantly on responding. I think that also at times made it challenging to share those pieces. We're a very small specialty, so we know each other across the country and I also think sometimes it makes people a little reticent to share anything that's personal or showing weakness, because we're a really small group. The reality is we take care of each other, but I think physicians often put the strongest foot forward.

Dr. Caroline Gerin-Lajoie: In your survey, your members expressed that one of their primary stresses was the gap in understanding between them and other physicians. Can you explain a little bit about what that gap is?

Dr. Catherine Elliott: When you look at public health and preventive medicine as a specialty, it's practiced in quite a different way from much of medicine that is clinical and practiced in research and other ways, but mainly in patient to patient-physician encounters. Our practice, our patient is the population, and our encounters are different, and our methods are different.

Dr. Catherine Elliott: I think one of the things that was the most challenging was, what I've heard from my colleagues, is around knowing that we have an area of expertise that is about influencing government policy, making evidence based decisions for the measures that we, whether it's public health measures or communicable disease control, the measures that we recommend, and also being a public face and that public communication piece. These are all our areas of specialty and one of the important gaps that many people felt, many public health physicians felt, was that other physicians were putting themselves forward as experts in public health and preventive medicine and either openly criticizing the local or national experts, or putting themselves forward as having an opinion that was equally as informed or practiced as the opinion of those experts. That could be at times quite challenging for people to hear and listen to, and to experience.

Dr. Caroline Gerin-Lajoie: Another source of intense stress from that survey was around moral distress. Can you tell us a little bit about what your colleagues were experiencing in terms of moral distress?

Dr. Catherine Elliott: What I've seen in terms of moral distress amongst my colleagues is that the recognition that we make decisions. Public health physicians need to make decisions for the greater good, but they may not be the best decision for every individual in the population. A good example of that is if you close a school or workplace because of transmission, you're sending people to spend more time at home. For many people that's healthy or good enough, but for some children you're sending them home to domestic violence or to home situations where they're neglected, where school is their safe place, or people in the workplace back to situations where they can't sneak out and see their physician in the middle of the day because they're in a situation of violence at home. The recognition that some of these impacts of the measures are part of the picture when you make a decision that's for the greater good of the population.

Dr. Catherine Elliott: Many of my colleagues experienced moral distress because of these things. When we recognize that the impacts of many of the measures, both in COVID, but other things as well, have the greatest impact on those who are already so impacted and vulnerable to really severe life challenges. When you see that impact it's been something that has been broadly discussed and also, I think in some private moments with colleagues has been brought forward in terms of just knowing what the impacts might be. I think another area of distress or moral injury has been situations where colleagues are in a position to make recommendations to government around what would be most effective to control COVID-19, and also to reduce the harms or the impacts of measures, and those recommendations are rejected.

Dr. Catherine Elliott: The path forward that the government has chosen with... When the government does see the social and economic and other impacts as well, and there's an important role for that. And yet for some colleagues have expressed a feeling of helplessness at watching something unroll that they did not have the power to prevent and they may have predicted could be coming. The reverse is true too. Not doing something because it's the best piece that, the best evidence based and clinical decision at the time to not take a measure or a step or do something to protect the population, because the harms are greater than the risk, and then things not turning out how it was predicted. All of these are pieces that have contributed to moral distress and people really taking that responsibility to heart and suffering because of their role in the pandemic response.

Dr. Caroline Gerin-Lajoie: So, Catherine, you shared earlier that you were worried about burnout and your colleagues in the first few months of the pandemic. Here we are almost two years in. How concerned are you now?

Dr. Catherine Elliott: People are really tired. Physicians are tired. Leadership is tired. The, the colleagues we work with, the nursing staff, environmental health officers, administrators, IT, media, people are very tired. That is actually now something that we raise at tables when we make decisions about the wisdom of X, Y, or Z decision with a tired workforce, because that is a real component of what we're currently experiencing.

Dr. Catherine Elliott: I also think during the pandemic the recognition of the different contributors to burnout became more evident. Contributors such as limited resources that in public health and preventive medicine, we are often working with limited resources. The long hours, not compensated and not also relieved by time off has been something that many people have been challenged by, and there have been some solutions along the way to that as well. I think it would, I think the frustration that comes from when our physician colleagues publicly criticize the work of public health and preventive medicine physicians is something that remains challenging and will continue to be challenging as well over the long term, long haul. And then just overall the workload and the wellbeing of our profession will take some time in order to recover from that.

Dr. Caroline Gerin-Lajoie: I'm pleased to hear that talking about workforce health is now part of your conversations, and maybe that's a sign of a shifting medical culture towards promoting health and wellness. Catherine, I'm curious if you feel that the work of public health officials has been properly understood or acknowledged, and how can we show gratitude to you and your colleagues?

Dr. Catherine Elliott: I feel that there are pieces of the profession that are understood, and there are other pieces that are not understood, and that's okay. I don't understand everything about cardiac surgery or gynecology or geriatrics or palliative care and that's okay. I would hope that there's some humility among physicians about what could occur that they're not aware of, or the pieces of our role that are more behind the scenes. I think one of the ways that we could, people could express gratitude is of course a simple thank you's lovely, but it's also just having that humility and recognizing in subtle ways that this is a field with its own expertise. It's a rigorous five year training program, and although the expertise is not always evident, and the decisions that are made are the science, the epidemiology, the communicable disease side is not always well understood how in our profession we knit that together into a clinical opinion. I think, recognition that it is an area of expertise and having some degree of humility in that area would go a long way as gratitude.

Dr. Caroline Gerin-Lajoie: Dr. Catherine Elliott, thank you for taking the time to speak with us, and also thank you for all the work that you do in public health.

Dr. Catherine Elliott: Thank you, Caroline. I appreciate the chance to talk about this.

Dr. Caroline Gerin-Lajoie: Dr. Catherine Elliot is a council member of the Public Health Physicians of Canada, and she is also the acting Chief Medical Health Officer for the Yukon. You've been listening to Sound Mind, a podcast about physician wellness and medical culture. If you're looking for resources, tools, and research on the topics covered today, please visit the CMA physician wellness hub, at cma.ca. I'm Dr. Caroline Gerin-Lajoie. See you next time.

Sound Mind: The personal cost of leading Canada’s public health response to COVID-19

Topics

Healing the Healers: System-Level Solutions to Physician Burnout

How healthy is your culture? Assessing wellness in your organization

BounceBack® program

How to Create Space for Joy in Work Amid Crisis and Change

Moral injury: What it is and how to respond to it

Minimize burnout and improve mental health among medical students

Are you in distress? Get help now.

Sound Mind: The personal cost of leading Canada’s public health response to COVID-19

Topics

Related resources

Healing the Healers: System-Level Solutions to Physician Burnout

How healthy is your culture? Assessing wellness in your organization

BounceBack® program

How to Create Space for Joy in Work Amid Crisis and Change

Moral injury: What it is and how to respond to it

Minimize burnout and improve mental health among medical students

Are you in distress? Get help now.

The personal cost of leading Canada’s public health response to COVID-19