What’s really ailing docs these days?

According to Dr. Katharine Smart, president of the Canadian Medical Association, the level of wellness among physicians is, by many accounts, at an all-time low and only expected to get worse. The National Physician Survey from 2021 showed levels of burnout never seen before. Physician wellness is at such dire levels that research now suggests suicide has become an occupational hazard. A study published in the Canadian Medical Association Journal in 2019 (notably, pre-pandemic) found that “suicide is the only cause of mortality that is higher in physicians than nonphysicians.”1 Of course, physician wellness issues have been around for many years; however, they have only gained a degree of prominence and urgency in about the last 10. As an example, Dr. Smart cites the unprecedented, new investment of millions of dollars in funding from the Canadian Medical Association to medical associations across Canada to help make physician wellness a top priority. Read: Hopeful and optimistic: New OMA president is keen to tackle physician burnout Physicians in nearly every jurisdiction have a variety of private, usually self-funded, associations that advocate for them to one degree or another. Those groups can often play a role in looking after otherwise busy physicians. While they have traditionally focused much of their time tending to the financial health of physicians with much success, they have now turned their minds to issues beyond dollars and cents. Most, if not all, of the national, provincial and territorial medical associations have some form of physician wellness program. They range from acute addiction counselling and intervention to help locating childcare, any many things in between. Significant human and financial resources have been expended by these associations and many other physician organizations to stem the tide of physician suicide, burnout, addiction and mental health issues. But have those efforts yielded results? Some physicians are trying to figure out just that. Are the efforts made by their own associations, regulators, departments, and educational institutions making any difference? Case in point, a young emergency room physician in Quebec sadly took her own life in January 2021. The response from some medical associations was to take to social media to declare the loss tragic and to tell the world that resources are available to help physicians in need. This type of response is questionable for a few reasons. First, it’s been done before, and to no avail. Sadly, this was not the first loss of a physician by suicide, yet the response of a tweet expressing condolences seems to be repeated each time. It hasn’t worked in the past and the stakes are too high to keep trying it. At best, the social media post was sincere but naïve. At worst, it was part of a flawed communications plan that harms the reputation and relevancy of these organizations. Second, it has an obvious tinge of victim-blaming, as if to say this person may not have chosen to take her own life had she just visited a website first. Doctors, of all people, should understand that those who are in distress to such an extent that they have suicidal ideation may not be in the frame of mind to navigate the internet in search of a website or 1-800 number. Third, and most importantly, it totally ignores the bigger issues at play. Doctors may be used to treating symptoms but they are also expert diagnosticians. They can often find the root cause of a problem—or at least try. Doctors know very well that the root cause of the growing physician wellness problem is not a failure to check a helpful website. The cause of physician wellness issues is multi-faceted but rapidly coming into focus. Read: Cutting "technostress" to reduce burnout According to Dr. Smart, the culture in medicine is one of sacrifice and martyrdom that perpetuates a “hero complex.” Physician culture values the health of patients above their own, which manifests in excessively long-hours, high patient volumes, and seeing reward in financial compensation rather than self-care. Dr. John Chiasson, a family physician in Antigonish, Nova Scotia, and head of Doctors Nova Scotia’s Professional Support Program, said physicians have been “socialized to solve other people’s issues not our own.” This physician culture perpetuates a stigma surrounding mental health conditions and interventions, thus encouraging physicians to keep their problems to themselves rather than proactively seeking help, suggests Dr. Leslie Anderson, a forensic pathologist in New Zealand. This physician culture has permeated medical training through a hidden curriculum, which Dr. Smart describes as indoctrinating and perpetuating. The hidden curriculum teaches resident-physicians and medical students that, according to Dr. Smart, there is a “badge of honour in staying up for three days.” Dr. Gurmeet K Sohi, a PGY4 geriatric medicine resident-physician at the University of British Columbia, says, “basics of self care including sleep, food and even bathroom breaks aren’t always prioritized and are often neglected in the name of patient care and service needs.” Deteriorating physician wellness isn’t just a symptom of an unhealthy culture but also an ailing healthcare system. Several physicians cited heavy workloads, limited resources, and a lack of autonomy and control as contributing to a high-stress and toxic work environment. Working in health care right now is like being in a “boat with a hole in the bottom,” says Dr. Smart. Policy-makers and political actors seem all too happy, if not resigned, to avail themselves of this unending supply of clinical service and care. Healthcare authorities are faced with unrelenting demand for care as well as a worsening shortage of healthcare providers. “The need is so much greater than supply,” according to Dr. Dennis Desai, Director of Physician Support and Wellness for the Canadian Medical Protective Association. Dr. Desai also described a common scenario that sees five physicians now doing the work of ten because there simply aren’t enough physicians. Those that remain must work harder and longer. They are taught and told that this is the sacrifice of being a physician. They then become unwell due to burnout, mental health issues, extreme fatigue or, in more recent years, COVID or Long COVID. This leaves fewer behind who must sacrifice even more to meet high patient volumes. The cycle continues. Governments and medical associations have been unable to break it. To add to that pressure, physicians are now dealing with an ever-increasing administrative burden through rapidly changing technology, complex EMR systems, new government tracking requirements, and needless and/or lengthy forms that healthcare administrators, insurers, and employers insist upon. One result of much of this is that the public perception of physicians may be eroding. There is plenty of anecdotal evidence that the role of physicians is changing, yet the profession hasn’t adapted or addressed it in any meaningful way. Physicians were once thought of as the keepers of medical information, says Dr. Anderson. This enhanced the view by many of physicians and the degree of deference afforded to them. The global COVID-19 pandemic has brought to the fore a trend that started years before. As reliance on the internet grew, some medical and non-medical experts quickly expanded their reach through social media by posting every piece of medical information they could find. Academic journals and research became readily available to the public and physicians at the same time. One can now find an abundance of reliable (and unreliable) medical information on the internet about just about any ailment imaginable. It’s not uncommon for a patient to have researched something before a physician has even had the chance. As a result, one need not rely solely on the doctor to learn all about their health issues. They can read all about it from the comforts of their own home instead of sitting for an hour in a crowded waiting room to ask a physician. As knowledge and information became so readily available on the internet, it’s possible that patients simply had less deference for physicians as they once did. Dr. Anderson articulates this conundrum in practical terms, saying, “I hear regular stories of my clinical colleagues being at best ignored by their patients in favour of information from the internet or an altenative ‘healthcare provider’ and at worst being abused and berated if the patient doesn’t get what they want from the doctor. So many of us are disheartened and frustrated.” One of the primary responses to all these dynamics in recent years has been to teach medical students, resident-physicians and physicians more about building tolerance or resilience. This over-emphasis on physician resilience while ignoring system-wide problems is “insulting,” says Dr. Smart, and “drives resentment,” says Dr. Sohi. Dr. F. Gigi Osler, President of the Federation of Medical Women of Canada and Past-President of the Canadian Medical Association, shared this view. According to Dr. Osler, “it is abundantly clear, and there is data to support it, that physicians are resilient. Focusing solely on strategies to develop physician resilience unfairly shifts the burden onto individuals and overlooks the responsibilities of our health care training and work environments to prevent distress and burnout.” “Focusing on resilience is physicians is a bit like victim-blaming. Nothing will improve unless the over-arching issues are addressed,” says Dr. Anderson, who trained in both Canada and USA. The ability to tolerate or withstand something deteriorates over time and doesn’t actually solve the problem. Building tolerance and resilience seems to ignore the diagnosis and instead bandage the symptoms. It was philosopher Jiddu Krishnamurti that said, “It is no measure of health to be well adjusted to a profoundly sick society.” Compounding physician wellness issues is the inability to properly measure these complex problems. “The best metric is a direct measure of physician stress and wellness,” says Dr. Desai yet many other measures are being used. Longitudinal, quantitative studies such as the National Physician Survey have been done and are helpful for a basic level of awareness. Rates of suicide, burnout and drug use are informative but not determinative. The University Health Network in Toronto uses a Wellbeing Index for all their staff. Nonetheless, if one measures what one treasures, surely there ought to be better metrics in place by now. What’s not clear is why physicians do not have a reliable, scientifically-valid metric that properly records the quantitative and qualitative nature of the problem. How will they truly measure and show progress without such a measure? So, what can do done? Read: Feeling burned out, Doctor? Go north and get on the river Non-physicians can do their part to address physician wellness issues by advocating for better healthcare through well-trained, healthy and available physicians. Poor physician health leads to higher turnover, more physician retirements, less physician availability due to illness and burnout, and less knowledge transfer. These dynamics actually increase costs to governments and tax-payers while limiting access for patients. Have medical associations done enough to measure and address physician wellness issues? Have they analyzed remuneration mechanisms to emphasize physician wellness? Can medical associations collaborate with governments to review health workforce planning? For example, Dr. Smart believes that the fee-for-service system fails to remunerate physicians from working in integrated teams even though such teams can help improve physician wellness. Dr. Desai believes a federal approach to health workforce planning is crucial to analyze the needs and mobility of the workforce. While emphasizing that more often than not, one physician is doing the work of many, he says, “maybe there are certain areas that are over supplied right now.” Dr. Anderson suggests billing codes for procedures that have undergone significant technological advancement and don’t require physicians to invest out-of-pocket could be reviewed and redistributed. Can medical education and training be changed? Dr. Sohi opines that, “recognizing and addressing cultural and systemic practices that drive burnout would be higher impact and that requires education and training of not just learners in the system but the teachers and administrators. Often practices such as 24-hour-call are justified as a means for service coverage and patient care but exploring novel and alternative models that still allow for adequate learning and patient care whilst maintaining basic self-care needs should be explored.” Whatever the answers, medical associations and other physician organizations often have political capital and financial resources to effect meaningful systemic and cultural change but it’s not clear if and how they have put that leverage into action. Given that good physician health is needed to ensure good patient health, we’re all invested in these changes. Whether the action and response from physicians’ own organizations is satisfactory in diagnosing and treating the root cause of this problem is up to physicians themselves to decide. We wish them, and us, well. Matt is a lawyer, professional communicator and consultant. He founded Maruca Strategic Counsel in 2020 to provide a broad array of multi-disciplinary and strategic legal and consulting services. He is also an expert in physician compensation and provides impartial expertise in court proceedings and in other dispute resolution forums. 1. Albuquerque, J. & Tulk, S. (2019). Physician suicide. Canadian Medical Association Journal. Read: The burnout drain

What’s really ailing docs these days?

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