‘In Dialogue’ Episode 10: Dr. Jillian Horton
In episode 10 of “In Dialogue,” 2022 CPSO Council President Dr. Janet van Vlymen speaks to Dr. Jillian Horton, a general internist, and award-winning medical educator, writer, musician and podcaster, about her personal struggles with burnout and how it manifested in her life, resources and strategies for coping and self-care, and treating one’s self with compassion.
Dr. Horton completed a residency and fellowship in internal medicine at the University of Toronto, and held associate dean and associate chair positions in that department. She is currently an associate chair of the Department of Internal Medicine and director at the Alan Klass Medical Humanities Program at the Max Rady College of Medicine in Winnipeg, MB. Her 2021 bestselling biography, We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing, follows her journey during a meditation retreat for burned out doctors and explores how a flawed system shapes medical professionals.
Related eDialogue Articles
- Reclaiming Herself (interview with Dr. Horton)
- Reaching Out for Help
- Pandemic and Mental Health
- Physician Burnout and COVID-19
- Patient Bias, Physician Burnout
- Pandemic-induced Mental Health Distress
- Being a True Ally
- The Cost of Working in a Culturally Unsafe Environment
- ‘In Dialogue’ Episode 2: Dr. Janet van Vlymen
- ‘In Dialogue’ Episode 8: Dr. Jon Novick, OMA PHP Program
- OMA PHP Program
- Canadian Medical Association’s Physician Wellness Hub
- A profession under pressure: results from the CMA’s 2021 National Physician Health Survey (August, 2022)
- Watch: Four physicians describe the causes and effects of burnout and ways to cope
- CMAJ podcast: “Med Life with Dr. Horton”
CPSO presents “In Dialogue,” a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.
Dr. Janet van Vlymen (JVV):
Welcome and thanks for joining us “In Dialogue.” My name is Dr. Janet van Vlymen. I’m an anesthesiologist and associate professor in the Department of Anesthesiology and Perioperative Medicine at Queen’s University in Kingston. I’m also the current president of the CPSO Council. As the medical regulator, CPSO is committed to engaging in conversations about the mental and physical health of Ontario physicians. We’re thrilled to be joined today by Dr. Jillian Horton for an extremely important conversation about the enormous pressures physicians are facing and to discuss strategies to address physician burnout.
Dr. Horton is a renowned physician, author, speaker, coach and podcaster. Earlier this year, the College spoke to Dr. Horton about her own journey and experiences as a practicing physician, and about her commitment to shining a bright light on the struggles physicians are facing. The CPSO Council had the privilege of hearing Dr. Horton speak at a council meeting earlier this year. And her eDialogue article from March of 2022 has been the most read and shared article of the year. Dr. Horton continues to create awareness about this systemic issue worldwide through her talks on a variety of platforms. Welcome and thank you for joining us, Jillian.
Dr. Jillian Horton (JH):
It’s my pleasure to be here with you, Janet.
JVV: It’s such a pleasure for me to have a chance to speak with you today. I read your book, “We’re All Perfectly Fine,” last year just before starting my term as CPSO president. It was so inspirational and helped me shape my goal to keep physician wellness and burnout at the forefront of all the work we’re doing here at the CPSO.
JH: Oh, thank you, I just can’t even tell you what it means to me to hear that from colleagues. It’s so gratifying and keeps me inspired to get going on my next book.
JVV: In our previous discussions, you had talked about why you chose a career in medicine and the fact that the medical system had failed your family, and, in particular, your older sister, Wendy. You described your quest to reform medicine as a hero’s journey from within. What would you say to your younger self about the challenges that that journey has had for you?
JH: What a beautiful question. Well, first of all, I think I would try to do something I never did in my youth, which is speak to my younger self with compassion and tenderness. And I think that’s something actually that’s pretty common, not just in the population at large, but especially to us as physicians. We don’t tend to excel in the area of self-compassion. So, that’s the first thing — I would mind the tone that I used to speak to my younger self. And the second thing, I would counsel my younger self is that that goal was not only ambitious, but impossible. A system, a culture is what marinates us. It is ubiquitous, it is the size of the universe. And so, we often set ourselves up, I think in medicine, to do things that are quite literally impossible. We think that furthering science is the hard part, but it’s actually the rest of what we’re doing. That kind of culture change, system change, really reframing the environments in which we work. That’s actually what probably moves at a more glacial pace. So, I would say to that younger self, that goal was noble, it arose from bearing witness to suffering and hurt, but probably a reframe. Looking at the way I now look at problems in medicine, especially as they pertain to culture, because that I think related to a lot of my family’s experience, what is the problem? What is the role of that problem in creating the culture? And then work on the problem instead of this big lofty goal that sets you up unequivocally to crash and burn, and then think you are the problem. We are not the problem. The problem is the system that we’re born into was broken to begin with and we never really understood that.
JVV: Yeah, I think that’s great advice. I’m sure it’s great advice for your younger self, but it’s great advice for all physicians, and particularly young physicians who may have gone into medicine for the same reasons: to try to make change because of things that they witnessed and a hope to make things better. And I think that advice about compassion and also sort of the pacing — you come in wanting to change the world and that’s a lofty goal, but it can burn you out very quickly.
JH: Totally. And I think the other interesting thing that happens is your orientation changes, because in the first phase of my life, I called myself an interloper. I was sort of infiltrating medicine with this almost grandiose, but again, very sincere idea, I’m going to fix this so this never happens to another family. And when you really pull back from that, you start to see the people, in many cases, who provided the care that was painful and traumatic, they too were a product of this system. And so that’s been one of the most surprising twists for me, is finding compassion for so many people for whom I just simply didn’t have any at the beginning, or people I saw in kind of a dichotomous good, bad, overly simplistic framework. So, I think that compassion when we can — the hardest people for many of us to find compassion for is ourselves, but in the process, we start to see “Gee, this person is just like me. They’ve also been deformed by this. They’ve also found themselves doing things, saying things, feeling things that they would have said were impossible for them at the beginning of this journey.” And a more compassionate orientation is one of the difficult requirements, I think, for all of us to continue to make some kind of change before we make this progression.
JVV: Yeah, and I think for patients and families that have had negative experiences, to realize that, sometimes for physicians, despite their very best efforts, you’re pulled in multiple directions, you don’t have enough time to sit and talk. And so having a bit of compassion for the other stressors that are going on for physicians and despite their very best efforts, unfortunately, sometimes patients don’t have the care and the time that maybe we would like to give them.
JH: Exactly. That’s a very formative part of that experience, in terms of their emotional orientation towards us as well.
JVV: Yeah. That’s great. Jillian, you’ve talked before about your experiences as a health care provider and as someone who is experiencing burnout, trying to navigate the healthcare system, looking for help and support. And just wondering, can you tell us a bit about how burnout manifested itself in your situation?
JH: So, for me, I would say I had very little awareness for most of my life that I was cycling in and out of burnout. I would say like most of us, severe burnout for me began during residency, which is hardly a surprise. But again, I think I completed my residency in 2004, and I would say at that time, our situational awareness about what burnout was, how it manifested, what it felt like, was next to nothing. I mean, we thought if you weren’t in a mental health crisis that you were fine. We, again, had a very dichotomous view, it was all or nothing.
And I think when I look back, we always talk about the sort of trifecta of burnout as emotional exhaustion, a sense of low personal accomplishment, and a kind of disengagement — we can’t really take pleasure in anything, we’re depersonalized, we don’t really feel like we’re in our work. And for me, looking back, what I really missed in the big picture was I felt engaged at work. I was 130 percent on at work, all the time. But then, what would happen: get in the car, come home and there was nothing left. What I often talk about is my spouse and my kids got the leftover garbage scraps of me at the end of every single day. Maybe there was a respite, maybe there was a vacation where I managed to be a little bit present, but then the emails would start coming in. And especially for me, that was the administrative work. And, particularly, the years when I worked as a Student Affairs Dean, I really took on everyone else’s problems, 24 hours a day. That kind of emotional labour that our deans, our program directors, anyone who’s tasked with the well-being of students, that work in general, we don’t really acknowledge or appreciate the toll that it takes on people to do it really, really well. And we never rotate them out of it for rest breaks. That’s certainly one of the things that I think many of us know intuitively if we’ve been in those roles or watched friends have those roles.
So, for me, I always thought, “Okay, if I’m burnt out, I’m going to feel it clinically. It’s going to manifest at the hospital, I’m going to be too tired to see my next patient. I’m not going to be as good at my family meetings or those really profound moments of emotional intensity.” That never happened. I was always pretty alive, present and engaged in my clinical work and my administrative work. But then I got home and I just think, you know, again — we’re always our own toughest critics. I don’t think there’s anybody else in my life who would say, “You are not being a good parent. You are not being a good friend or family member or spouse.” But, I know the comparison between the nine out of 10, 10 out of 10 energy level that was always present at work, and coming home and just really not being available for anyone, having no energy to do anything. And I think that’s actually a really important distinction, because I think we have such a work orientation towards burnout, we really think about burnout as a professional problem, which it is, of course, but we forget that we can also diagnose that professional problem by looking at the impact that maybe those three things are manifesting exclusively in our personal life. And I think for many of us, because we prioritize work over everything else, because we have been conditioned to do that, we don’t even know that we’re doing it or that we’ve been conditioned to do it. I think when you see that personal piece, people go, “Oh, really? Yes, I do relate to that. Actually, I feel like a complete failure in my personal life, even though I know I’m not, but my work life’s fine, so how does this apply to me?” That was how it applied to me. And that was the beginning of real insight for me in terms of acknowledging and beginning to deal with the ways in which work was, I think, slowly poisoning me and having a deleterious effect that shouldn’t be acceptable to any of us.
JVV: It sounds like even close colleagues probably wouldn’t have recognized that because you were holding it together so well at work and performing at probably more than 100 percent. One of the problems, I guess, right? Because even people close to you in your workspace may not recognize what you’re going through.
JH: One-thousand percent. And I think that is a hallmark of us as physicians and it’s a line in my book that we’re fine until we aren’t. So, for sure. You know, again, when we think of burnout, people in trouble, we think of the extreme manifestations. We sometimes think of disruptive physicians and looking more deeply at what’s going on, is there something that we’ve missed in the process of just labeling them and judging them. But we don’t really think that much about the people who always seem to have everything together, and be carefully managed and cultivated. And this is one of our skills —looking fine, when we are not fine.
And I do also just want to add that in addition to burnout is sometimes I think in a burnout conversation, we can be euphemistic. Sometimes people are saying I was burnt out when what I was really struggling with was depression and they never say the last part. So, people kind of walk away without having the understanding that they need to identify the problems in their own life. And I would say clearly, for me, a lot of the times when I was burnt out, I was not depressed. Burnout, for me, did not have anything to do with depression because there were periods when everything was completely fine. There were separate issues, though, going on at different points in my life. And I do just want to say I’ve written about them in the book, I’ve been very transparent, but I think it can be, I hope, helpful to other people to acknowledge them. And certainly for me, during my residency, and at a few other points in my adult life, an eating disorder was one of the things that I concealed from the world and one of the ways in which I coped. I think with the immense stresses that we all feel, that we sometimes don’t know what to do about them. And we go very quickly from adaptive to maladaptive. So that was another ripple, another thing. And I do see at times how, when my burnout would get worse, that sometimes the symptoms of that disorder would also get worse.
But just to be really clear, for me, burnout — I’ve never been diagnosed with depression, I’ve never been treated for depression. If I had been, I’d be happy to say that because I think we have a lot of colleagues sharing that kind of information. They’re critical, profound, meaningful, useful disclosures, and the two constructs are separate but related in literature. I just think it’s helpful to talk about as part of these transparent conversations, “Okay. Is she really talking about something else?” In my case, I’m not, but there is something else that has also woven throughout the course of my life, as I think is of course, for many of us.
JVV: Yeah, absolutely. So, from your personal experiences, as well as the work that you’ve done with physicians and learners, what do you think their reasons are for why it’s so difficult for health care professionals to ask for help when they’re struggling?
JH: One of the things I think is modeling. It’s very hard for us to go first. It’s very hard to do something that you have never seen anyone else do in your own immediate environment. So, maybe you were at a conference or maybe you’ve read a book and someone is doing this in another city, or you are really touched by an article that you read. But the immediate environments that we work in still do tend to be our primary focus when it comes to, for example, things like our fear of social pain. So, I sometimes talk to people about the psychological process that I went through in putting a book like mine out there or even when I write in a very personal op eds for the Los Angeles Times, for The Globe and Mail or the other outlets that I write for, sometimes one of the biggest fears that holds us back is that social pain, the feeling that I’m going to — if we again move that to the local environment instead of a newspaper, I’m going to say, “Gee, guys, I’m really struggling. And I want everyone to know that I’m struggling right now. And I reached out and I sought help. And I’m seeing a therapist right now because the last two and a half years on top of the last X number of years have been totally overwhelming.” I think one of our biggest fears is that our peers will say, “Yuck, why did she say that? Oh, well, we all knew that she wasn’t as tough as the rest of us.” And so that is one of the biggest challenges that we face: local environments, local culture, local dysfunctional culture and finding support within those realms is one of the hardest things.
And the second thing I think we all face is that our suffering has been completely normalized; that we have had these little hints — if I think back to my residency, people who at the time looked completely impenetrable to me, attendings that I thought of them as just… it was inconceivable to me to think that those people had ever had an emotional life that was anything like mine. I mean, part of that is immaturity. We don’t really think of people who are older than us when we’re young as having the same complex in Earth life as we do. But the second thing is, again, if nobody’s talking about it, it’s natural that we would assume that it’s only us. It sort of mirrors to me the kind of egocentricity of childhood. Something goes wrong in your family — your sibling has cancer — you think I must have had something to do with that. And I think that egocentricity carries on. Honestly, medicine is like recreating. It’s another period of formative years and then moving out into the world on your own. And I think it’s a simplistic explanation, but I do feel viscerally that a lot of those same patterns just repeat themselves. Our formative years, the things that we do, become the patterns that repeat over and over in our adult life. And I think we see that happening in medicine. We acquire and observe and imitate toxic, repressive patterns of behaviour, and until somebody shows us another way, in detail, and makes it safe for us to explore that other way, it’s very, very hard for us to change.
JVV: That’s one of the reasons why I think your work is so important, because you have these platforms, you have a voice, you have the book and the articles and podcasts and things, and really, for people to hear struggles happen and there’s help and we can move along. And I think your examples of the local piece is very important, and it’s harder to change because, of course, we can’t have that influence at the local level. But having someone like yourself who, at least if it isn’t happening locally, at least they’re seeing somebody they can model after.
JH: I love that point, Janet. And I think even more broadly, if I look at what’s been really helpful for me. So, the book I wrote, of course, is about mindfulness in one sense. It’s a memoir, it’s about my lived experience in medicine, but it’s also about going to this retreat, where I learned mindfulness. And mindfulness was very helpful to me as psychological PPE, as a stabilizer. But I think there’s another critical ingredient in the piece of how that whole experience really did change my life. It’s the community. It’s that it was the first time in my entire life that I had ever sat with another group of doctors. And these are people from all over the world, people from the top institutions in North America, very senior people, people that on first pass I would look at and think, “Why are you here? What’s your problem? Give me a break, it’s not going to be anything like mine.” I mean, what delusion and arrogance in that view, what limitation. And yet, it’s what we all bring to that. But that community piece. And then, not just for those five days and the other retreats that I’ve gone to, but that community lives on for all of us in chats, in phone calls, in zooms, in collaborations. And suddenly, if you feel like the odd person out in your immediate environment, if your immediate environment and your immediate cohort are maybe not people that you feel deeply close to or that you feel you are psychologically safe, to have those conversations, then at least that somewhere else lives. Those communities are very real, they’re vibrant, they’re ongoing.
And for me, I also have had the opportunity to do chief wellness officer training at Stanford. And that community is also one that is cultivated and watered and nurtured by Stanford. We meet four times a year. We meet once a year at the ICPH or ACPH. And so again, what I find so interesting now, let’s say I write an article somewhere that is a little bit scary or intimidating for me to put something on paper, but I do it anyway. I have a few friends here who I will share it with and they’ll say, I love it — or maybe not, I don’t need them to say they love it. But the people that I typically get the most positive and encouraging feedback from are often the people in those two non-physical communities, the communities that are spread out all over the place, that gives me so much strength and so much courage to just keep going. It’s so validating. And I wish everyone could have the benefit of a community like that, or find a community like that. Because for me, that has been transformative and allowed me to keep pushing my own boundaries in terms of comfort and to feel that it’s okay, it’s important, and it’s of some service to the cause.
JVV: I think those communities are growing, so they’re becoming more accessible to everyone. I think that’s one of the important things. And how we can sort of publicize and bring forward to people who have access to those resources to say this is something that’s available to you, even if you don’t have any community, so I think those are really great points. So Jillian, there’s a lot of research on physician burnout, and the impact that it has on patient care and safety. And we know that physicians who aren’t well, they’re not able to provide the best care for their patients without taking care of themselves first. So, can you tell us a little bit about what you think the barriers are for physicians to be able to access that kind of care that they need?
JH: Yeah, it’s a wonderful question. So, of course, stigma is a big problem. A second problem is that the literature suggests that we’re not really that wonderful at identifying our own burnout. Some literature, one nice study particularly looking at surgeons, when they evaluated their own well being compared to peers, a majority of them thought that their well being was superior to their colleagues, which is obviously not possible. And also, when they were in distress or their well being was actually quite inferior to the rest of their colleagues, they didn’t do a good job of identifying that. And again, I think it speaks to, if we take a step back and we say, “What are we trained to do?” We are trained and conditioned and taught systematically to plow through our fatigue, to suppress and repress our emotions during difficult times, to not be allowed to acknowledge or even articulate them in real time. And I know sometimes people listen to that and they go, “Oh, well, are you supposed to burst into tears every time you do something difficult?” Of course not. I mean, but I do hear that; you read those kinds of comments if you waste your time reading chats around articles. There’s always someone who intentionally misappropriates what you’re suggesting. And it’s really just about, in real-time, naming what your feeling and articulating it to yourself, acknowledging it, saying, “Yep, it’s there, I see it.” Instead of, I think what happens to so many of us, we lose the ability to even name what we’re feeling.
It’s really interesting when I work with groups of physicians and I teach them this mindful practice program, which is some of my favorite work that I’ve done in my professional life is sharing that with colleagues. And you say to a group of physicians, “Where do you feel stress in your body? What does it feel like? Describe it.” And I had this experience myself, the first time someone asked me that, I go, “I don’t know. I don’t really know. I don’t pay attention to my body. I’ve got a job to do.” And just think about that for a moment. “I don’t pay attention to my body. I’ve got a job to do.” That, I think, embodies what a lot of us — again, we don’t come to medicine this way. Sometimes we’re selected for our ability to be that way or that’s become the way that we’ve coped with adversity in our lives. But I think then we say, “Gee, is it any surprise that later in life or at that stage in your life, that you would not be able to recognize that you are in trouble, that you are burnt out, that your mental health and your physical health and your performance and your engagement and your sense of emotional well being has deteriorated?” We tune that feedback out and that is not our fault. We are encouraged, whether overtly or through the hidden curriculum, to do that. So, I do think — and again, if we go back to that first excellent question you asked me of how burnout manifested in my own life — that’s what I see and just paying no attention to that data.
The last thing I’ll say, I think there is — for multiple reasons, medical exceptionalism being one of them — the idea that asking for help is a sign of weakness is a long-held belief as part of our, again, overt or hidden messaging. I think one of the most important things we can do is make that process as simple and transparent as possible. The more steps required to seek help for any physician, the more opportunities we have to talk ourselves out of seeking help. And so, I think I’ve certainly been through that myself as well at different points where, okay, if I had to call and then do something else and something else, I go, “But I don’t really want to do that.” I’m speculating as to all the things that can go wrong: “I’m going to get Janet, who knows me, on the phone and it’s going to be really awkward and terrible.” And so, it gives us more opportunity to talk ourselves out of the process. We know looking at anything from an organizational behaviour point of view, the more streamlining the better. One call, one click, the referral’s been made or the connection’s been made. Those kinds of things are really important for us too, because many of us are looking for reasons not to engage with those processes. We know on one level, maybe, that we need help, but we sort of talk ourselves out of it.
JVV: I think just having that one button and I think the fact that it needs to be available 24/7. You need to be able — maybe the time you have that realization is just before you’re going to bed and you think, “Oh, I really need help.” But the next day you’re up and you’re at it and the work that many of us do, we’re busy, we’re in very public places all day long — you couldn’t, there’s no way that you would be able to make a phone call during business hours to have a conversation like that. And you just may not feel emotionally prepared to unburden yourself that way, while you’re holding it all together in a workplace. So, I think having those ways where you — like one email and then the logistics of who, what, where, when, how is being looked after by someone else who knows what resources there are and what might be available to you. So, I think those kinds of things for organizations, not that it’s helpful for maybe the solo practitioners, but organizations I think are making headways, which is really great.
JH: Yes, exactly.
JVV: So, I have a question for you. We know that microaggressions and discrimination take a toll on physicians’ mental health and wellness, and just wondering what your thoughts are on how physicians can still continue to treat patients with care and compassion when they’re worn out from dealing with the additional burdens of discrimination?
JH: It is such an important question. And the first thing I find myself thinking of is, it’s really important for us to acknowledge as you just have with your question, Janet, that this is real, because I think there’s still a lot of gaslighting around this issue in terms of, you know, you kind of infer… so, for people who are members, for example, of racialized groups — until someone else, or let me rephrase that. There is incredible power in someone else, who is not a member of your racialized group, saying, “I now have an early understanding. I will never know what it is like for you to experience that.” If the colour of my skin is white and I have a colleague who is a member of a racialized group, and they have experienced microaggressions, macroaggressions, not only in their life, but we’re talking specifically about the clinical environment. We, of course, I don’t think any of us, I hope none of us would ever say at this point in our lives that we understand because we don’t understand. But we can begin to say, “I’m aware that this is a cognitive and emotional load that I never have to deal with.” You and I have to deal with gender discrimination, perhaps, in our work environments. Or maybe if a person has a disability, they have to deal with ableism. And that’s its own cognitive load as well. But there is so much power when those in power acknowledge, “I do not understand what this is like for you in terms of your lived experience, but I see that it is real. I see that this is a whole load of work, an injustice and indignity that weighs on you. A rock in your pocket every single day that nobody ever puts in mind.” The power of people articulating that, that they recognize not just that it’s unfair, it’s wrong — and both of those things are obviously true — but that it makes your work harder.
And even when we think of… if we take a step back, one of the things I find has been helpful in teaching this concept to groups where maybe there is not a lot of diversity, I love this study done in 2015. It comes out of the UK literature, looking at how often people experienced rude, dismissive and aggressive behaviour in their clinical environments (RDA). And we know from that study that the younger folks who reported RDA — most people experienced RDA three times a week — but the younger individuals experienced it twice as often. And it’s such a great example, because we all age. Some of these other factors, we will, I will never have a different colour of skin, but I am older now than I was. And it illustrates for people in a way that everybody has the capacity to relate to, “Yes, when something about me is changed, my experience is different.” And we all can understand, intuitively, as I get older, I have more privilege, I have more seniority and I’m typically treated with more respect than my younger colleagues in the hospital, who have to put up with more micro and macroaggressions.
So, I think beginning with the validation, and secondly, what I always talk to people about as physicians, we speak in evidence — that isn’t always in our best interest, actually, because sometimes it means we cut ourselves off to other ways of knowing that things are true. The stakeholder analyses, story-based methods of sharing experience that do have their own intrinsic validity. But really, showing that data for what we know the experience of our racialized colleagues, our colleagues with disabilities, our colleagues who have experienced homophobia, transphobia, the literature tells us that their experiences day-to-day in medicine are different. Knowing, showing and the cognitive load perspective, there’s so many other angles to look at that from, but I find it’s viscerally understood by people. And the metaphor, again, I always use is a rock in the pocket. So, two doctors going through their day. One, their white coat pockets remain empty. The second doctor every hour gets a large rock put in their pocket. And at the end of the day, say, “How was your day?” And the person with the empty pocket says, “Well, it wasn’t bad. I feel pretty good.” And the other person is exhausted. And what does our system typically say because we can’t see those rocks, because they’re invisible to those of us who don’t have them put in our pockets? We go, “That other doctor is weak. They’re not tough enough. They’re the problem. They’re the ones wrecking our fine, brave, strong, powerful culture.” So, I think sometimes thinking of the metaphors that will best allow people who are open-minded to learning — some people are not open minded to these concepts. And leadership, as we know, if you don’t have the right leadership, leadership that believes that real problems are problems, like problems around EDI, you won’t move the dial on it. So, when people are ready to learn about these things, those are some of the ways that I find helpful — ways that have helped me as well to understand experiences that I can never really understand, but to begin to apprehend them from one person removed, and to think of how I can be a stakeholder as well and improving those situations for colleagues.
JVV: I love that metaphor because, to me, it’s very visual. You can see and you can feel the burden, and how tiring that would be for someone all day long. So, I really, really liked that metaphor. And speaking of leadership and the role of leaders, administrators, I have a question that, of course, as the CPSO, how can regulators, like the CPSO and other health institutions, help to support physicians health and wellness so they can continue to provide safe, quality health care to their patients?
JH: What a lovely question. And, you know, the first thing is, I think language is really important. So, the language that we use when we formulate policies and standards, when we communicate with members. I think we’ve all had situations for any organization that we’re affiliated with in medicine, where we get something — and I’m not speaking about anything in Manitoba, I’m just speaking panoramically over the course of my career — you get something and you think, “Ugh, this sounds like I did something bad or this organization thinks I’m about to do something bad and they’re warning me that they’re watching.” This is a tone that alienates everyone, that does not suggest alignment of mission, of a sense of why we’re doing what we’re doing. And I think it’s important for, of course, all of us to acknowledge, every organization that is a stakeholder in physician health, so that includes our regulatory colleges, our provincial medical associations, the organizations that we work for, patient organizations, everyone is going to see this problem from a different perspective. And everyone also has competing interests. And we know, of course, that the colleges exist in part to protect the public. And it’s just as long as we are mindful of the fact that everyone’s vantage point is different.
But then we think about alignment. How moving from tones that feel punitive, critical, harsh, how does communication make us feel? I do think that’s really important. And I’m sure I’m not saying anything that is in any way a revelation to you. But I have been part of different working groups on different things, looking at standards, language that’s used and if we start by saying, “Thou shalt not,” nobody wants to be spoken to in that way at any point in their life. It’s not an emotionally intelligent way of communication. So, I think that is certainly one thing that we can begin to do. Really, really reflect on the tone of communication. And also, how would this tone feel incongruent with what people are experiencing at this moment in time. I saw some communication from another province that someone shared with me early on in the pandemic that reminded physicians of what a privilege it is to be a physician. And I would argue that was the wrong time to remind people of that. I hope we all remember that. I try to remember it constantly. But there are times… I compare it sometimes to we know how powerful it is to engage with gratitude practices. Lots of science that engaging with gratitude practice makes us feel better, is a powerful antidote for negative emotions. But how, if most of us experienced gratitude earlier in our life, it’s as a punitive thing. “Don’t forget to be more grateful. Don’t forget to write that thank you note to your grandmother. You should be grateful that you have a full plate of vegetables when some children have nothing.” We’ve experienced it as kind of punitive. And there’s an indirect lesson there, that we can be saying something that is true and really important, but in a way that the other party experiences as just more finger wagging.
And I think that sometimes, it’s like our conversations about professionalism. We’re really talking about disruptive physicians who were like 2.5 to 4 percent of the [physician] population, but we’re speaking to the other 96 percent of physicians with the same tone. And I think there’s something there that’s worth reflecting on, too. I would also say, when you think about what’s important, I think having the kinds of conversations that you’re initiating within these podcasts and your pages, normalizing them, saying to people, the College doesn’t look at this and go, “Oh, too much. What if there was a PHIPA violation in a person writing about their clinical life?” I mean, I would assure you and everyone listening that legal vetting is a deep part of a process of writing any book like mine to make sure that one never violates the sanctity of PHIPA. But I think even that framing for things that people might normally think, “Oh, what would a regulator think about this? Is this too much? Is this oversharing? Can you write about patients?” We are what we champion. And so, I think that is something for any regulator, continuing to do that is important and powerful, and is part of rewriting that hidden curriculum as well.
JVV: I’m so encouraged to hear that advice. And certainly, you’re not practicing in Ontario, but the tone of the messaging is something that we’ve really been working on for the last several years. So, I think through the pandemic, there was messages from the registrar, supportive messages recognizing the toll, the burden, also resource-based messaging as well. And then we’ve really tried in all those sorts of communication, you get a letter with the CPSO at the top of it, and it’s “personal and confidential,” and your heart races. But I think that it speaks to the fear of the regulator. So, we’re trying to work on the fact that we’re not out to find bad doctors. We all have the same goal of providing safe care to patients and so we’re very aligned — we should be — in that goal. And so, some of the work that we’ve been doing is really around that messaging and implementing right-touch regulation. So, using the right hammer for the right nail.
And then the other thing that I think is important that we all keep in mind is around culture. Just because something bad happened, doesn’t mean you’re a bad person. Even if it was a true error or a mistake, we’re all human. And so, it’s important that our members know that that is something that is really working its way through the culture at the College; recognizing that as much as having a College complaint and maybe a caution, and to be told that you did this thing that was wrong — you already know that and you’re even harder on yourself than anyone else could be. So, I think it’s really, really different than a pattern of behaviour, like you talked about, a very small portion of disruptive physicians who maybe are not learning from their mistakes, that are repeat offenders. But I hope, and it’s certainly been the work over the last several years, is really changing that tone and that mindset to be one of more of a supportive tone and understanding. So, I’m glad to hear that those are your recommendations and gives us more fuel to the fire of the work that we’re doing.
Jillian, I wanted to thank you so much for sharing your time with us today. And it’s just been an absolute joy and pleasure for me.
JH: Oh, thank you so much, Janet, and feeling’s mutual. Thank you for hosting this conversation and for making space for these types of dialogues. Because, as I say, who hosts them, the where and the framing — these are powerful things I think that we can begin to do to rebalance some of what is off kilter in our culture. And I’m just so grateful for your leadership in that regard.
JVV: Thank you again.
JH: Thank you so much.
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