'Power list' doctors on burnout, activism and being a leader

One of the great things about being a journalist is you get to talk to interesting people! I was so impressed by the insights doctors on the Medical Post's 2021 Power List had:

At the beginning of the year, the Medical Post put out the 2021 Power List of the 30 Canadian doctors with the most “sway.” Then, in April, we held an invitation-only Zoom meeting with many of the doctors on the 2021 Power List.

We asked the panelists to answer four questions from med students, residents and new-to-practice doctors.

Here is the transcript of what these doctors had to say about these four questions:

·      Dr. Danyaal Raza: Outgoing Chair of Canadian Doctors for Medicare

·      Dr. SaritaVerma: Dean of Northern Ontario School of Medicine

·      Dr. James Makokis: Two-spirit and Indigenous role model     

·      Dr. Jane Philpott: Former cabinet minister and dean of Queen's medical school

·      Dr. Mamta Gautam: Physician wellness advocate

·      Dr. Tara Kiran: Primary care researcher and scientist

·      Dr. Verna Yiu: President and CEO of Alberta Health Services

·      Dr. Alika Lafontaine: incoming president-elect of the CMA

·      Dr. Gigi Osler: Former CMA president and equity and diversity champion      

·      Dr. Sacha Bhatia: Virtual care champion·      

·      Dr. Suzanne Strasberg: Chair of the CMA board of directors.·      

·      Dr. Lisa Calder: CEO of CMPA·      

·      Dr. Jennifer Kwan: Family physician and COVID explainer on Twitter.

·      Dr. Samantha Hill: OMA past-president

SUPPORTIVE HEALTHCARE WORKPLACES

Q1: In shaping the health system of the future, how might we learn from the pandemic to build a healthier and more psychologically supportive workforce and workplace?—From: Avery Ohman, a first-year medical student at U of T

Dr. Verna Yiu:

I think the importance of having a psychologically safe workplace is something that should happen regardless of whether there is a pandemic or not. I think what the pandemic has really uncovered for us is the relentless nature of what we’ve all been going through and the increased stressors that we have on our teams.

But after saying that, at least within Alberta health services, we’ve put a lot of thought into what we call the “People Strategy,” which we established more than five years ago. Because in order for us to push a patient-family centered culture, you really need to have the people and the people supported in order to provide the care.

Yet you can’t go out with a patient-first strategy if you don’t actually have a very strong people strategy. So we did that a few years ago. Along with our patient-first strategy. And it’s all centered around quadruple aim. Anybody who knows healthcare, of course, know that quadruple aim is really about improving patient experience, improving patient outcomes, improving the people support as well as making sure that you got a sustainable efficient organization to be able to do all of that and so when we did the People Strategy, we had input from more than 60,000 of our staff physicians and volunteers. To really tell us what areas should we be focusing on and there were four areas that we really needed to improve on.

One was to make sure that we have a shared common purpose, one was to make sure that we have a safe, healthy, inclusive environment, making sure that we’ve got excellent leaders, we know how critical our front-line managers are to the system as well as the physician leaders who have a very strong diet model at Alberta. And then to make sure that our people are empowered.

So we’ve now moved on to our phase two or our people strategy 2.0, and we’re really focusing on progressing a culture that we can all be proud of, especially a team-based culture. Making sure that we actually have people supports in place, supporting our leaders, and very important: supporting our workplace because we know how important the workplace is to ensuring that we build a strong team culture in all of that. So just to say that this is all been in the works.

I think it’s an evolution of a high performing healthcare system and that at the end of the day, we should be taking advantage of what the pandemic has brought to us—perhaps a silver lining to say that we actually need to progress on ensuring that our workplace is a workplace that we can all be proud of and exponentially increased to one where we can all work in. So, I think just the last thing I want to say is that we do know the stressors on our staff especially now.

I just want to end up by saying that it’s really important for all of us as clinicians in the system, to have self-compassion and to give ourselves permission to look after ourselves. We’re very good at looking after others. We’re, perhaps, not so good at looking after ourselves. So my plea to many of the young up-and-coming leaders is that we need to also, take our own responsibility to be compassionate to ourselves and be compassionate to our colleagues.

Dr. Suzanne Strasberg:

The Canadian Medical Association had an opportunity to think about this quite a bit over the last year as we’re developing our 2040 strategic plan. I think that the pandemic forced us to take a hard look at the choices we made as a society and a profession. I think that the challenges that we’re facing today were already (there) and (made) more evident. Maybe they were bubbling a little bit under the surface and never really quite hard enough to force real change but I think we now have a burning platform to act on a range of fundamental and structural issues.

I think that the social determinants of health have to be considered when we think about how to help patients live their best lives and systemic racism and discrimination in the health system has to end. And I don’t think that we can any longer ignore the issue of equity, sustainability, and integration of our health system. But I think the pandemic’s also reminded everyone of a really important fact that doctors and other health professionals are humans.

And it may sound trite but we need to start with one of the fundamental changes: creating conditions for physicians in all healthcare professionals to be their best selves at work. Because I think that’s how we offer Canadians the best care and how we can be the best colleagues to each other. I think it’s why we’re seeing evolving medical culture as one of our long-term priorities in our strategic plan at the CMA. In can be toxic.

We’ve heard that from a variety of physicians at different places in their careers and if this question is being asked by a first-year medical student, then I think there is a burning platform for change. So I think that we need to shift to prioritizing well-being, diversity, respect, leadership, excellence and care. And that change has to take place at the top as well as to bubble up from the bottom.

So I think that we just have to assure that physicians and medical learners have access to the right resources and support to promote and maintain their health and wellness and that they can seek help without fear of reprise. We’ve heard that a lot at our roundtables and from a variety of stakeholders. I think the last point is critical whether it’s a learner who’s afraid to speak for fear of not getting a residency spot that they’re looking for or physicians who are afraid of other repercussions. Healthcare workers shouldn’t be silenced and I think we need to deal with stigma but we also need to deal with the systemic barriers that are silencing people who need help.

Dr. Sarita Verma:

When you deal with students on a regular basis (it is clear that) what is apparent and what actually happens are two different things. We live in a society (where) both clinical and academic medicine is based on a hierarchy, a hidden curriculum, and one that is actually fairly difficult to manage because of power differential. So it’s okay not to be okay but when you’re not okay and you speak up, there’s a lot of stigma associated with it.

There’s also a culture that we all trained in. I’ll challenge any of you to argue with me: that we were told that if you didn’t give your whole life to work and that you weren’t available 24/7 that there was something wrong with you.

So the first step towards this form of reconciliation, I believe is acknowledgement that it is a human job.

The second one is the recognition that it takes a lot more than saying you have to be resilient, you actually have to create systemic and institutional structures to help people manage the difficulty with the psychologically unsupportive environment because it’s risky and it’s actually a very challenging environment. People are upset, they are emotionally overwrought, there’s a lot of tension and then (with) COVID, there’s actually even more high intense situations in which people find themselves. So that creates that level of fight and flight. That’s not part of our training in terms of who we are as people in healthcare. So I would say that one of the most important things is to actually acknowledge that the work hours are dreadful and that we need to be able to actually change the system dramatically to be able to do what we say: which is walk the talk of healthiness.

Dr. Lisa Calder:

This is a really tough question right now. And the reason it feels tough is …we all want to support physicians and recognize the importance of wellness. But physicians have been challenged unlike ever before. (For) a lot of people, their surge capacity is diminished, their ability to take on more is diminished, and as much as we speak to the lesson of self care, it’s a very hard thing to live right now.

That said, I also hopeful that a medical student is asking about psychological safety because psychological safety is something we’ve been talking about in patient safety for years but is something that requires intention, it requires practice, and it requires nurturing. And I think that if we have future leaders who are interested in establishing psychological safety and having a dialogue about what are the conditions to do that, that is very hopeful for me.

I think also it’s a universal experience: building on what Sarita said about medical students being in position of seeing something that they know is worrisome and fearful of speaking up. That is a universal experience. So if that’s the case, and again I do think that has been accentuated in the COVID-19 pandemic, the sense of people stepping into risk and a healthcare environment unlike anything they’ve ever had to do before, it requires courage and bravery and willingness to be vulnerable and talk about what that means and feels like.

So, it feels hard now, but I do think the more we talk about: how do we establish psychological safety in our workplace, the more hope I have of examples of where it works well and then—one of my colleagues calls them black pearls—where you see that it’s not working well and what do you learn from that and how do you grow from that. So I think that the issue of psychological safety is one of the keys to advancing the culture in medicine towards a more positive place.

Dr. Jane Philpott:

I want to just give a bit of a shout out around inter-professionalism as I think one of the most positive outcomes of the pandemic—and we’re all looking for positive things—(is) I have seen the level of collaboration across the health professions and between, for example, primary care and specialty, between hospitals, public health, and family medicine working in a way that they, at least here in the Kingston community, they have possibly never worked. We’ve seen walls being taken down across the health professions where we see the chief of staff at my former hospital in Markham Stouffville was doing shifts as a critical care nurse because she knew that that was the biggest need in the hospital. That’s fantastic when stuff like that happens.

Where we start to realize that the things that divide us are much smaller than the things that join us together and we have to hang on to that recognition of the fact that the preservation of medical hegemony does not benefit anybody and certainly it doesn’t benefit our patients. And until we continue to realize we are part of a team, this is critical that we continue to work together and recognize that everybody is essential, that will make our workplaces more psychologically safe and keep the workforce going for the future so I’d like to hang on to that lesson.

Dr. Gigi Osler:

I just want to say it makes me a little bit sad that a first-year medical student is asking this question. Because to me that means they have seen colleagues who don’t feel psychologically supportive or that they’re working in a workplace that is not psychologically supportive or safe. And this is a first-year medical student.

At the same time, I have some hope when I see the faces around this table and when we have medical learners and people just starting out in their career asking these types of questions because I don’t think I was this evolved when I was a medical student. I was just clueless and you just worked and whatever came your way, you put up with it and you did it.

And I think this question speaks to culture and the hidden part of the culture, if you think about that iceberg, everything that’s under the water, all the -isms, all the microaggressions that eat at you everyday and we’ve got leadership and I see leadership on this call and I know there’s leadership who are committed to changing culture and creating psychologically supportive and safe learning and training environments.

I see (a) future physician workforce that is more diverse. But I always think it’s that middle, it’s that hard immobile middle when we’ve got pressure from above and pressure from below, it’s that middle part of the physician and the learner workforce, how do we affect change in culture, how we treat each other and support each in particular during COVID? And so that’s what I’m interested to work with and learn more about and hopefully with these colleagues and others, create change.

Dr. Alika Lafontaine:

So as has been said by several of my colleagues here, these issues aren’t new. They’ve just been magnified to the point that we can’t ignore them anymore. That’s been both the negative and positive part of COVID. The good things that we’ve been doing have gotten better and the things that we haven’t been doing so well, have gotten worse.

I think inside the question, there was probably something about what do we do about this? And what I suggest to medical students, not just this one but any learner, is that you go out and find a mentor and spend time getting really immersed in the system before you get too set on a direction or solution for what you do.

I remember years ago actually being under Verna Yiu as we went around talking racism across Alberta Health Services when she was VP and I can tell you I’ve learned so much about the system through my experiences with her. Sometimes we think we have to fight against a system that’s unfair when we actually are the system. And so as we move forward trying to fix these problems, don’t forget that we are the problem but we’re also the solution and so we have to find a way to still humanize each other as we move past and create a better healthcare system.  MP

DEVELOPING AS A CLINICIAN AND A LEADER

Q2: How can you balance developing as a clinician and as a leader early in your career?—From: Dr. Melanie Bechard, just completing residency, a pediatric emergency physician in Ottawa

Dr. Samantha Hill:

I just want to throw out there that the idea of balance is a fallacy; it’s something that we all have to stop striving for and touting like it’s an achievable goal. Any of us who have young families, any of us who have more than one active goal in our life knows that some days you win at something and some days you lose at other things.

Someone once said to me, “We’re all juggling too many balls and you don’t get to keep them all in the air, you just get to decide which ones you’re going to drop on which day.” I’ve carried that metaphor through a lot this year because obviously you can’t be as good as you want to be at everything all the time. And so it’s about giving yourself grace, figuring out what balls you can drop, where it’s okay to miss a meeting, where it’s okay to cancel clinic day, and where it isn’t, and then moving forward with your eye on the priorities that you want.

Dr. James Makokis:

I think this is a really important question and especially for those who perhaps might not have mentors for whatever reason, it is an important thing to think about as a younger physician.

I really take advice from Oprah Winfrey, who has this saying, and I don’t know if anyone has read her book or seen her on tour, but she talks about the stages of development that she’s gone through. Really starting in her twenties where you start to figure out what you’re good at and what your priorities and then in your thirties, you work really hard at honing that craft and putting the time and effort in which I feel is where this person is. They’re starting at the beginning of their career, they’re starting their specialty, and then in their forties and fifties is when you reap the benefits of those rewards. And so I think now is the time of putting in that hard work and it’s really focusing in medicine, where it is that you want that to be.

Picking a couple areas that you can be successful or that you’re passionate about and I think those are important reflective questions to ask yourself (such as), “Is this going to make me happy?” And I don’t think that there is anything wrong with asking ourselves those questions. “Is this going to make me a better person?” I think is another question. “What am I going to learn from this?” And lastly, “What am I going to get out of this?” And I don’t think that’s a selfish question to ask. Those are the things that I ask myself when approaching things because there’s so many things that come in to our paths and we have to prioritize that.

And lastly, how is this going to affect your home life? With your partner, with your families, is it worth doing those activities if it’s at the expense of missing a baseball game or a concert or different things which you’ll never have the chance to do again.

Dr. Tara Kiran:

I think for me, my clinical work is what has always grounded me and I would urge people who are early in their career to really focus on feeling comfortable in building clinical skills. This is something that you’re going to carry through the rest of your career and you need to feel really good about it early on. And also it’s something that if you want to be a leader moving forward, it’s going to be hard for people to respect you in the same way if you aren’t good at your first job, which is being a doctor.

For me, medicine is also such a privilege because we get to hear and meet and interact with people, hear their stories that we normally do not get to in day-to-day life. And I think it’s that perspective that you continue to have as you do clinical work, you see what’s happening on the ground. You can’t address issues of wellness and burnout among your physician colleagues or political injustice to the same degree, I don’t think, unless you’re seeing that on a day-to-day basis on the ground as well and speaking from those front-lines.

So we see some of the most effective leaders, I think, actually during COVID-19, being the ones who could actually share those stories and I think it illustrates how important it is for us to centre ourselves in our clinical world.

I’d also like to just build on a couple of things that other people have said that. I think we don’t have to always look for balance on a day-to-day or week-to-week or even a one year level but we can look for balance and think about our career over the long span. And so it might be that there are times early on that you are prioritizing clinical work and family and then you move on to putting in more stuff in terms of the leadership. Once you got your groove as a clinician, it is much easier to put more stuff on your plate. But when you’re early in your career, that can become, I think, a lot more challenging.

The last thing I just wanted to end on is this notion of imposter syndrome. Many of us have really high standards for ourselves and it’s important to have high standards in many respects but sometimes we’re too hard on ourselves. And I think many of us if we’re juggling different roles, we feel like we’re not doing well enough in our roles perhaps as a mother, or as a clinician or as a leader. And so try it, if you can, to think about how you can get some more objective evidence so you can understand how you really are doing, not what you may think you’re doing inside, but what do other people think? Are there objective elements that can help you gage where you’re at to help you to better balance where it is that you need to put your time.

Dr. Mamta Gautam:

I really appreciate hearing the comments from our colleagues and their wisdom and their experience that they’re sharing here. I love Melanie’s question because there’s just that acceptance that ….we can’t do it all that there has to be some sort of balancing act. I like that there’s some inherent approach to this. And I often talk about the difficulty that we have in medicine for balancing, which as we’ve all agreed is an illusion, right, there’s no such thing as a perfect balance. I say it’s kind of like a workable balance and it works for as long as it works. That might be a few weeks, that might be a few years and then we find another workable balance and it’s really a series of that.

I think that what makes that so hard for us is certainly what I’ve learned from my colleagues is that there’s just so many things we want to do. If we were all average and there were three things we wanted to do, we can do them all. But because there’s 53 things we want to do, we can’t do them all. So the challenge for the balance, for (lack) of (a) better word, is that it requires us to say “no” to things we want to do. To say “no” to things that we’re really good at. To say “no” to things that everybody else is asking us and beseeching us to do. That’s why it’s so hard for us and when I say “no” to things, and I think back to James’ point about the concept of different priorities and different phases. So I say to people, the two words for balance, one is the choice, you have to choose out of all the things that you like, what you’re going to do right now and then the second word is phases.

That you make that choice for this phase in your life and in another phase, you can choose to let go of something and take up something else that you dropped but we just can’t do it all the time.

I love the idea to recognize that the clinical role, we will come back to our CanMEDS roles, our role as a clinician is firmly in the centre. So that’s something that as long as we choose to work in clinical medicine is always going to be a priority; to give the best possible care of our patients. I think that while we do that, that provides leadership roles. We can be leaders wherever we are. So, I urge our trainees and our junior colleagues and our peers to really look at: where can I take a leadership role in this and sometimes we have a formal role that we’re lucky that gives us some influence but we all have influence in so many ways and I encourage everyone to look at what is in their sphere of influence and take a leadership role in that.

And before I stop, I’m going to put in a plug for compassionate leadership. I just cannot tell you how important that is. That has been important, as I look back in my three decades of work, and it’s never been more important than in the last year and 14 months. And that requires you and whatever leadership role you’re in to lead not just in the mind but from the heart. To be vulnerable and to have that emotional intelligence of sharing vulnerability and just sharing those stories, recognizing that we’re all in this together. And it’s more than talking about this, it’s about actually acting, right, acting to create an environment where people do, back to our first question, feel psychologically safe but see you actually doing something about the issue that are a concern and a problem. And again, I’m so excited and so privilege to be on this panel with all these compassionate leaders.

Dr. Alika Lafontaine:

This discussion reminds me of working on the Indigenous Health Alliance and I remember trying to get meetings with minister Philpott at the time and garnering support and advocacy from the Canadian Medical Association, the Royal College, and Canadian College of Family Physicians and other stakeholders. I think what Mamta was talking about saying “no” to things that you want to do is something that comes later in the leadership journey because you’re not really sure what you should say “no” to early on. I remember during those years, I said “yes” to everything. I think I was doing 10 to 20 presentations every single month. I had to scale down my clinical to half-time, but over those two to three years where I really put my heart and soul in the project, I learned a lot about leadership where now I can sit back and I know what to say “no” to.

I know what’s going to bring value to the things that are important to me.

It’s mixed messages that you’re getting here as far as leadership but for the things that are really, really important to you, clinical experience, say “yes” to all of that. Leadership experience in the areas that you’re interested in especially early on your leadership journey, don’t be too, too picky about the opportunities that you get. Because you’re never sure where you’re going to gain that experience, later on you’re going to get that experience of what’s going to really be high value to you. 

ACTIVISM

Q3: Should physicians have more of a role in political policies and how do we make that happen?

From: Dr. Christine Nicholas, just completed a fellowship in Microsurgical Breast Reconstruction and Melanoma at the University of Calgary

Dr. Danyaal Raza:

I think this is a good question because it’s not just a question of should physicians have more roles but it’s also which physicians. I think we’ve seen the make up of medicine change. But we’ve seen that shift happen at leadership more slowly.

The group assembled today is an exception to that rule and (things are) starting to change. But when you look at, for example, a lot of the media work that’s being done where physicians have been very persuasive in terms of shaping some of the conversations that we’re having around everything from paid sick days in Ontario to long-term care crisis, it’s still very male dominated and male heavy. Also a lot of the hard-hit communities in the pandemic also don’t have that same sort of representation within the medical world.

So I think it’s not just a question of should doctors have more of a voice in politics or public policy but it’s also, which doctors currently do and which communities don’t have that physician representation and why.

I think Alika made the comment earlier that the pandemic has really highlighted some things that have been really positive but it’s also really shown the cracks in so many ways. And I think within our community as we look to see as a profession how can we evolve after this, I think that’s one of the things that we need to think about and think about deliberately. And I will say even as a leader in the various roles that I have, it’s also something that I’ve had to grasp with in terms of how I operate and the way that I develop teams and I think that’s something medical leadership needs to do across the country.

Dr. Samantha Hill:

I have a few thoughts on this. First and foremost, I think it’s important to realize that physicians, as Dan was saying, are a wide spectrum of people and I am loathe to tell physicians that they should take on any more work right now no matter what that work is. Because most people are just so at their wits end.

But the truth of the matter is: physicians as a whole are very bright, they’re very motivated, they’re very hard working, they’re good at collaboration, they’re good at working across teams, and they’re good at innovating solutions because, let’s face it, that’s what we do 20 to 24 hours of our day in our current system. So I think that there is space and there is a need for physicians to have a leadership role in bringing solutions together now.

I think it’s also good to remember that once upon a time in smaller communities, your single physician in the community would have the ear of the mayor. Your single physician in the community would walk over to city hall and say “Look, I’m noticing this. There’s a problem.” And people would listen. That’s changed a lot. But part of it is because we’ve stopped reaching out the same way.

We see the effects of health care systems on the ground. We bring unique views about how policies affect each specialty. We’re so siloed that, as a cardiac surgeon, I barely have any indication or any understanding of what’s going on in an ID practice. And the Infectious Disease practice people don’t understand family medicine. And so it is important that while we bring our perspectives and while we bring our knowledge and our capacity, that we do so with that lens of humility. That we don’t actually know everything.

The other part is that I feel like physicians are often very angry with politics and policy. For a lot of good reasons sometimes—but one of the things I’ve learned this year is just how much more complicated it is then we first think it to be. Getting involved, getting informed, being part of that solution, it empowers you to be able to manage that emotional response much better and to actually be able to have conversations that are meaningful as opposed to reactionary.

Then the final thing I’ll say before I turn it over to someone else, is that I think we really need to have clarity, and someone else could probably speak to this better, about the division between public health and politics. Currently they walk a very fine line between trying to maintain health and to work within the policies that are available. And that seems to have created a lot of challenges in particular during this year. And one of the things I’d really like to see happen—I know other smarter people have called for this before—is separation of public health from the political agendas and the political parties.

Dr. Jane Philpott:

I can’t help but say something on this. I actually don’t think it’s an option for physicians (to decide) whether we have a role in public in policy, we have a role in public policy. You can’t be responsible for people’s health without thinking about what makes people healthy and what makes people sick. Public policy decisions are bigger drivers than biosciences in terms of deciding who’s going to be well and who’s going be sick in society.

So it’s whether we choose to exercise that role and how we choose to potentially have an influence. We may or may not choose to directly insert ourselves into the development of public policy from a political or apolitical lens but it has to be on our minds because it’s all about why people come to see us as clinicians.

Politics is nothing but medicine writ large. I think everyone on the call probably knows Rudolf Virchow’s famous statement. But I think that Samantha emphasized something that is super important about that statement because if you read the rest of what Virchow said, he said that “doctors have the obligation to point out problems and attempt their theoretical solution.” We’re actually really good at theoretical solutions to public policy but the politicians, who Virchow calls the practical anthropologists, must find a means for their actual solutions. As Samantha has discovered the actual solution is often much more complex than the theoretical solution. So I do think I will echo my colleagues plea for some humility amongst ourselves in terms of the fact that there’s a lot of anger currently. I absolutely think that people need to speak out with passion but also recognize that things are never as simple as they appear on the outside.

So (we have to find) our way: Do we want to be the angry activist? Do we want to be the behind-the-scenes drop over to your local politician and have a cup of coffee kind of conversationalist? We don’t really need to judge one another on how we choose to exercise that influence on public policy. We need to affirm those who do so loudly and vocally while also recognizing that that’s not necessarily the way for every single person to exercise their influence. It’s a super important conversation.

Dr. Sarita Verma:

I don’t want to miss out on the possibility of mentioning that it doesn’t have to be (as) an individual physician. That groups of physicians, as manifested by many of the organizations that are somewhat represented here, (can play a role). But also by the medical schools. So NOSM itself is mandated with the social accountability mandate. You can’t be in Northern Ontario and not recognize that there are issues with food security, water security and personal security. Everything from all of those issues to delivery and accessibility of health care as well as vaccines (and) health inequities that are a result of COVID have been exposed. So the role of the medical school is to advocate and that is using its influence to change policy and to develop policy.

I think that we have to work together and find common ground and as learners and physicians coming up the pipeline (on) everything from advocating for the patient who needs a disability form filled out to the groups of people who want to change helmets or seat belts (laws). It’s actually what we’ve done for a long time.

Dr. Sacha Bhatia:

This is a great discussion and I think we all are saying something similar: that it is great for physicians to engage in policy change.

The other thing that I would just say wis that physicians are not a homogeneous group. They are heterogeneous in terms of their background, they’re heterogeneous in terms of their political ideology, they’re heterogeneous in terms of their knowledge and specialty and what they’re comfortable with. What’s amazing about our community is that there so many different ways that people can engage in the process.

I think Jane said during the pandemic there have been some very public ways that people have engaged and that’s wonderful and I applaud them. I also think that there are many people that have done things behind the scenes for years. Doing things that are probably less sexy. Physicians have been on the front-lines of changing things from advocating for seat belt laws or smoking cessation or engaging in a different dialogue in the way that we train our next generation of leaders.

(There) are those that go all the way to either working for a political office or engaging in elected politics. (But) the point is there is space for everybody and I really hope that people who sees this, they don’t feel like they have to necessarily fit into a specific box. That there is a space for you and that there should be a space for you and people may not necessarily agree with what you are doing or you may not think it’s all that consequential but I see physicians everyday engaging and making positive policy changes. I just want to encourage everyone in their own way to get involved. Don’t be afraid of getting involved in your own way whether its medical education, advocacy, clinical stuff on the ground or, as Samantha said, talking to your local mayor or your politician. Local hospital politics is a wonderful way actually to engage in making real on the ground change in your community. There’s a million ways to get engaged and I would encourage everyone to do so.

Dr. Verna Yiu:

Sacha, I really appreciate what you just said because it was similar to what I was going to say which is: For physicians, it’s not a matter of if you should be doing this, you should be doing this, but the question is how?

There a multitude of different ways of actually engaging and trying to influence the system. Personally for me, I actually went into the health care system because there’s only so much I can influence in terms of health care outcomes within a university setting and so my choice to go into (the provincialized) systems was for that reason.

One of the things that I really want to highlight, and it was something that Alika had said earlier, was that physicians are part of the system. You own the system whether you feel it or not. So being able to know the system, have a knowledge around the environment that you’re in whatever environment it is whether it’s in the community, the university or the health care system, you’ve got to have a bit of awareness and be strategic about how you want to engage.

The comments around (a lot of) the anger coming out and always going to the media first, that’s not actually the most effective way in many respects in my mind. So how can you do it in a way that actually works within the system to actually move things forward? I believe that you can actually do more (with) understanding—especially medical students and residents, they come in and they do all their training (but) the gap once they graduate to going into the system is tremendous. How do we actually educate them? Get them more involved and more knowledgeable so that when they actually go out into practice, it’s not like they have to learn about a whole new world?

So just want to encourage people to be a little bit more strategic, be thoughtful; the humility is absolutely critical and know there are multiple ways to influence the public health agenda.

Dr. Danyaal Raza:

This comment is specifically for trainees: The thing that made a really big difference for me was to pause and really take a step back after I was done with my training. My first year in practice, all I did was do clinical work and take on a bunch of little commitments in a lot of different places. The reason why I think that’s so important is because when you’re a trainee, if you’re interested in something beyond the straight up clinician, then there’s very specific ways that you see that being done—become a particular researcher (or) become a hospital administrator, go do a PhD or Masters. So if you want to engage in the sorts of activities that I think that we’re talking about today, it becomes very difficult for you to imagine it because you haven’t seen it being done in front of you.

I think it’s a bit frustrating because we recruit all of these talented and bright people who bring all of these life experiences and we tell them that these are specific ways you need to be. I think you need to keep that open mind as you go through. Explore and then pick up where the opportunities present themselves through the relationships you built by doing a lot of little experiences before you commit yourself to doing one big thing.

The other thing I’ll also say is—maybe to push back on some other points—I think there’s certainly a role for people to push for change within the system. But any large changes—especially the change that I think we need now within the health care system but in society more broadly, as a result of the pandemic—it requires a lot of people to make a lot of noise outside of the system too.

I think we also need to recognize that the source of big changes that we need, it requires a diversity of people and diversity of voices and voices also sometimes (that) make us feel uncomfortable. As physicians, we tend to be a bit conservative—not necessarily our politics but in our approach to problems—but there are people who are out there who are street nurses who are operating unsanctioned overdose prevention sites. People who are working with factory workers in environments where they don’t have workplace representation. Who don’t necessarily have traditional access to leadership. So they’re going to the media, they’re working with activists who are there for them on the ground. So I don’t want us to be overly dismissive of those voices too because those voices are critical for any kind of social change.

Dr. Suzanne Strasberg:

Just a couple of comments based on my experience in organized medical politics for the last 20 years: The voice of physicians is essential. I think that we’re on the ground, we understand our patients, we understand what the problems are. But very often, physicians are their own worst enemies. In order to really affect good public policy change, you have to work with government and governments have a short life span. They’re almost always in election mode within a year and a half of taking office and we have to help them solve for what they need to solve for.

Often, in my experience, people of my age, want to hold on to the status quo and there’s benefits—self benefits sometimes to holding on to the status quo, but if we always say “no,” governments go around you. I think that probably things are changing but I think that we also have to keep in mind that we have to come forward with solutions to problems in a way that is good for the profession, is good for healthcare workers and, absolutely, first and foremost is good for Canadians.

Dr. Lisa Calder:

I just want to say real quickly: I’d be remiss as the CEO of the CMPA if I didn’t make a plea for professionalism in how physicians advocate.

We have seen a lot of really positive advocacy on the part of physicians during the pandemic, unlike we’ve ever seen before, people really speaking up, raising their voice, flagging concerns, sharing information rapidly through social media platforms.

We have also seen that some physicians feel that—and I understand it comes from a lot of emotion—that the expectation of professionalism doesn’t apply. I’ll just underline what Verna said: everyone wants to be an effective advocate, so it’s really important to ask yourself, how can I be effective? Because sometimes when we have that sense of emotion, we may use words that actually are impairing our efficacy and impairing the perception of us as a profession.  

BURNOUT

Q4: Maintaining your personal life and self care while balancing a leadership and clinical career can be very challenging. What suggestions do you have to make sure you can participate, be engaged and lead effectively without burning yourself out?—Dr. Ali Damji, in his second year of independent practice at the Credit Valley Family Health Team in Mississauga, Ont.

Dr. Jennifer Kwan:

I really appreciate the suggestions that physicians have previously mentioned on the panel about burnout. The way I see it is: I feel like there’s a piece of bread and you’re peanut butter and you only have so much peanut butter that you can spread. And at points, especially during the pandemic, you know when you spread it so thin you can still see bread? I feel like that. And then you still have more pieces of bread to spread.

I think that as physicians, when we go through our training in school, all our time is spent studying and training that we kind of put away, temporarily, other priorities so that we can succeed in our careers. But once we graduate and start working, it’s hard to know when to stop. That’s for me.

Once you’re practicing, you want to build your practice, you want to develop a medical career so it’s kind of difficult to get back into prioritizing your family and hobbies. Like, what are hobbies? At some point, I feel like I forgot about that. What was really helpful for me was having very supportive colleagues (where) we can be open with one another about whether we are experiencing burnout or needing a little bit of additional help—especially when there are different life circumstances. But (I’ve also met) many other supportive physicians and colleagues (who) have been mentors for me and (been) guiding me through this process.

I think that as physicians, we really do need to support one another, whether it’s in political advocacy or for day-to-day work and just building us up so that we can also be healthy while caring for our own patients. As physicians we also like to tell our patients to exercise and eat healthy and have a good work-life balance and I don’t think we listen to our own advice enough.

Dr. Alika Lafontaine:

I love that peanut butter analogy!

We’ve talked a lot about burnout as being this work-life balance thing, I strongly believe that if work environments don’t change, burnout will not improve for physicians.

The reality is our leaders within the health systems or health regions or health authorities, they’re only given so much peanut butter. It’s a government decision of how much peanut butter we stock and there’s a lot of coded language that we use right now as far as funding training systems and health systems, things like: fiscal sustainability, being responsible stewards of taxpayer money, etc. When in reality what we’re really doing is just cutting the amount of funding that eventually gets down to front-line workers and I think, post-pandemic in particular, we have to realize there’s just not enough to spread around.

We have to reinvest and that we can’t go further than we are already. We’re still talking about ways that we can cut and be more efficient when in the midst of the pandemic it’s very clear that we don’t have enough front-line providers and we don’t have enough persons working within units to provide the increased amount of care that we need.

The decision of whether or not I go into work, is different than someone who doesn’t work in medicine. If I don’t show up for work, someone doesn’t get their cancer taken out. If don’t show up for work, someone doesn’t receive critically important life-saving interventions that impact the rest of their life. And so for physicians, we feel an obligation to go to work and work harder and harder in an environment where we’re given less and less because of policy decisions made in very, very high levels.

I’d really encourage learners to go out and really advocate, we really need to invest more in health care. We have to stop cutting. There are places we can find efficiency, but for the most part when it comes to front-line, I think we’re very close to that limit of how far we’re able to go with what we have.

Dr. Sacha Bhatia:

Alika is absolutely right about the system.

Just personally I would say: your career is long. You don’t have to do everything at once. That was something I learned the hard way as I’m sure others have as well. This sounds glib but it is kind of okay not to be okay. Often times physicians have to put up this veneer that everything is going really well and the reality is that almost all of us, I’m sure, at different points in time of our career and, probably now, it’s actually not great. We have to be okay with that, we have to be okay with our colleagues and I do think we have to start to have conversations not just about our successes but about our failures and we have to make failure an okay thing.

Like personal, professional, whatever—and make it something that we talk about: (as a sample as) a researcher, you always see on Twitter when somebody gets a grant. But nobody ever writes that they didn’t get a grant and as somebody who just before I got this (current) job, had four grants rejected, the reality is that it doesn’t feel great. It’s all this expectation that’s happening and the fact that we don’t normalize the fact that we’re human beings. I think we have to start doing that as leaders. The fact is the only reason a lot us are here is just because we’re stuck in the game a long time. Not because we’re any smarter or work harder than anyone else. I think we just have to begin to normalize the fact that we’re human beings and that we’re going to go through struggles.

Dr. Gigi Osler:

I’ll echo what Sacha just said: as somebody who’s been in medicine for 23 years, I learn more from my mistakes.

When I read that question, I thought back to when I started out in practice 23 years ago: was I able to integrate leadership thoughts (and my) professional career and my personal life? Could I integrate it then? No. Now 23 years later have I figured out how to be engaged, lead effectively and not burnout? Also, no. But what I have learned is that you need to know who you are and what fuels your passion within that. We heard earlier how priorities will change depending on where you are in your career. I learned to recognize who needs me right now and what do I want in my life. That helped me at different stages to prioritize where I was going to put my time and energy.

I’ve also learned it’s important to know what is my purpose in the world. There’s this Japanese concept called an ikigai which refers to purpose or meaning of life and (there are) concentric circles: if you can find something that you love to do, something that you’re good at, something that you can get paid for, and something that the world needs, if you find that sweet spot right in the middle, that is when you are at your most truest expression of yourself. It’s hard to find that. Often you will find two (circles) where they’ll overlap or three. But (it is great) if you could find that four. I often keep that in mind as I go through this stage in my career figuring out what to do next.

Dr. Samantha Hill:

I just want to emphasize that burnout is really about system-level issue and we’re doing a lot of focusing right now on what we, as individuals, can do to try and reduce our own burdens and that’s very important we all like to feel like we have control over our own life and our own mental state. But most of the things that Iconsider which have, at times, threatened me with burnout have been far beyond my control. When I took on this role, I carved out five to eight (p.m.) for my children and I said I will always be available for my children five to eight. I think I probably manage it about half the time. And so it’s the difference between what we (intend) and what we try to do versus what the systems needs us to do and where we fall into those traps.

It is important to build resilience, it is important to build our capacity, it is important to say no, it is important to find our true purpose but at the end of the day, we’re working in a system that has far more demand and far less support than we need it to have to be able to do our best jobs for our patients. I think that is where most physicians struggle the most: is that we want to do good by our patients, we want to do well for them. And when we feel like we can’t because of the system lack of resources, there’s no amount of yoga meditations or eating healthy that’s going to change how that feels. MP