In our inaugural episode of “In Dialogue,” CPSO EDI Lead and Medical Advisor Dr. Saroo Sharda speaks to psychiatrist and physician health expert Dr. Mamta Gautam about her work in physician health and well-being, biases faced by women and racialized physicians, as well as working to ensure the delivery of quality care.
Dr. Gautam is an internationally renowned clinician, consultant, certified coach, researcher, speaker and author in the areas of professional health and professional leadership.
As a psychiatrist who treats physician colleagues, Dr. Gautam also hosts a free, daily one-hour Zoom call at 4 p.m. EST to offer mutual peer support, and a space where colleagues can feel free to share their feelings and concerns about working in Ontario during the COVID-19 pandemic. Please email Dr. Gautam directly to join.
Related eDialogue Articles
Physician wellness:
- Reclaiming Herself
- Reaching Out for Help
- Pandemic and Mental Health
- Physician Burnout and COVID-19
- Patient Bias, Physician Burnout
- Pandemic-induced Mental Health Distress
Bias:
Quality care:
- Interprofessional Collaboration
- Patient Safety — Interprofessional Collaboration
- Clear Communication in High-risk Transitions
Additional Resources
- CMA Wellness
- OMA PHP Program
- CPSO’s Equity, Diversity and Inclusion Resources
- Watch: Four physicians describe the causes and effects of burnout and ways to cope
Interview with Dr. Mamta Gautam
Dr. Saroo Sharda (CPSO Medical Advisor / EDI Lead) in conversation with Dr. Mamta Gautam (Psychiatrist and Physician Health Expert)
Introduction
CPSO presents "In Dialogue" — a podcast series where we speak to health systems 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. Saroo Sharda (SS): Hi, and thanks for joining us In Dialogue. My name is Dr. Saroo Sharda. I'm a practicing anesthesiologist in addition to my roles as a Medical Advisor and Equity Diversity Inclusion Lead at the CPSO. I hope you enjoy this episode.
Good morning, Mamta. It's so lovely to have you speak with us today at CPSO about your various expertise, your various experiences. I wonder if you could just introduce yourself and tell us a little bit about your clinical practice, and also all the other work that you do with women in medicine and leadership.
Dr. Mamta Gautam (MG): Thank you so much. First of all, I have to tell you, it's such a privilege to be invited to speak with you this morning, and to talk about some of the work that I do that, obviously, is very meaningful to me. I am a psychiatrist in Ottawa, I've been practicing here since 1990, and the focus of my clinical work has been in terms of helping colleagues in distress. Some of that has expanded to other professionals, but really, I think the main focus is taking care of colleagues, and now, my specific area of focus, one day a week, is treating colleagues with cancer when they're first diagnosed, or when there's a recurrence, or when they're looking to adding palliative care. So, that's my clinical focus. I’ve probably been doing that for about 30 years, in terms of treating physicians in my practice.
About 20 years ago, I realized that a lot of the issues that we were dealing with in terms of physician wellness were not really things that we could "fix" in my office, and really started to appreciate the system level factors. And part of how I decided to try and address that was to expand into developing physician leaders, and hoping that as physician leaders started to take on those roles in the healthcare system they would have, probably, a wider understanding of the importance of healthy medical workplaces. And then about 15 years ago I actually added some coaching, particularly to help physicians in their leadership journey. So, a really exciting combination of areas of focus — all very, I think, meaningful, but intersecting very nicely to support each other. And a particular area of focus for me would be supporting women colleagues in medicine, and making sure that women leaders are representing the women that are in medicine today.
SS: It's so fascinating to hear about these intersections, Mamta, and I think, we're going to get more into talking about how some of them came about. So, maybe I'll ask you, though, just about your personal journey, as a woman in medicine now for the past 30 years. Could you talk about what some of your greatest joys have been in those 30 years and, also, what some of your greatest challenges have been, particularly as a woman in medicine?
MG: Okay, well, I'd love to start with the joys. I would say, probably the biggest joy for me has been the ongoing privilege of being able to take care of my colleagues. So humbling to be able to make a difference, and feel that there is that sense of trust in coming to me, to help them achieve their previous level of health. I have to say, I add to that, the joy of working with learners. There are days where that is what I look forward to, because that's what reminds me of how exciting it was, how motivating, just that extra stimulation, and, of course, reminding me of the importance of maintaining my own level of learning and making sure that I'm on top of things, so I can teach to our learners. So, that part is really important to me, and I must say another joy has been — I'm hoping that at least some of what my children saw me do in medicine is what has inspired at least two of them to start medicine themselves.
But, there have been challenges along the way, and I think the challenges that I have certainly have been experienced by other women in medicine as well. One big one would be just the professional acceptance of women in medicine. I think that many of us have had that experience where we've had to work harder, do more to prove our level of competency, and sometimes that has eroded or impacted our sense of confidence — looking at just how much we have to keep doing to be accepted as equals. And I think the other thing that wouldn't add into their day-to-day medical care is an extra level of sensitivity, of compassion, which again, and, certainly when I first started in medicine, there was no room in medicine for emotions, and that was the kind of stuff you just had to talk through and deal with on your own when you got home. So, I think that sort of professional acceptance has been a challenge.
For sure, the gender bias. There are so many examples of inequities and microaggressions, and sometimes macro-level regressions, and for someone like me, I think, who finds gaps in the system, finds things that could be better, and advocates for improvement, I think if you try and change the system too much, that's not as well received. And so that's certainly something that I've experienced, and I would say the other challenge really, has been balancing family and our professional obligations. I think that women in my generation helped to lay some of the foundation so that we do have more women in medicine today, and we can support each other in a way to allow some of what's important and necessary for us to happen and be available in our workplace, but a lot of that was not as acceptable 30 years ago, and I'm not sure if I can say this, but I will. Like, both of the pregnancies I had, I remember going to my Program Director, and each time having somebody say some equivalent of, "darn!", or some sort of negative comment in response to that. And that was just what was expected, and you were kind of, you're felt to, to really be adding a burden if you chose to have a family as a resident and or even as a young attending.
SS: It's so interesting to hear you talk about those sort of generational changes that have happened, and certainly even in my career, over the past 15 years, I have seen some of those things improve over time for women in medicine. But it's also quite striking how many things haven't changed. I'm thinking about your pregnancies and the comments you've gotten, similar comments that I got when I was pregnant, not necessarily from a Program Director, but, certainly, from colleagues, and certain working conditions that I was in in the operating room that I never should have been in as a pregnant woman.
So, I wonder if I could sort of segue a little bit into when you're taking care of physicians, which is a big part of your practice, have you noticed any particular challenges for women in medicine in the realm of sort of burnout and mental health challenges, particularly that women have? Because I know there is some data out there showing that women physicians do tend to have more burnout, particularly if they're trying to balance competing demands outside of their work? Could you speak a little bit to that?
MG: Yeah, absolutely. And, you know, really, it's what you've just said, where women in medicine are facing much more challenges on a day-to-day basis than their male colleagues, and so are at risk of higher burnout. And what we see is, partly, it's the day-to-day work in the hospital, and it is dealing with some of these professional challenges that we've talked about, some of the gender bias. I think the other thing that we see is that a lot of the work that women are asked to do is not necessarily officially recognized, or in some way, but it's a lot of work. The other thing that we see for women in medicine are what is called "status leveling activities." So, the sense that there is a reality that women are seeing as having a different level of status, and some of this is among our female colleagues, and some of it is among the female members of the healthcare team, who behave differently with our male colleagues than they do with us. And so, we see examples of this. We see examples of women surgeons helping the nurses clean up in the OR and get ready for the next patient. We see examples of women making an extra effort to be friendlier to the women in the healthcare team, to be Facebook friends, to ask about their kids. And again, part of that is what we want to do, but the reality is that women are sometimes penalized if they don't do that. And so, all of this actually adds another hour or more to your day.
And of course, just dealing with some of the micro-inequities, or even the more overt harassment during the day in the workplace, and then the reality too is whether you work outside the home or not, women, and specifically women in medicine for us, bear the brunt of the child keeping, and the housekeeping responsibilities, and so we're seeing as caregivers — that's part of what we do. And what's really interesting is that those family issues don't go away when you get older, or your kids get older. We're still expected by society to be caretakers, perhaps of our aging parents, or our siblings, or the extended community. So, that persists for a long time, and I think that when we add up these extra burdens in our personal and our professional life, certainly does put women at higher risk for burnout.
SS: And I wonder if you could talk, Mamta, in a related question around where some of those intersections might lie for women who have intersecting identities? So, I'm thinking for yourself as a woman of colour, whether there have been particular barriers with that intersection of gender and race. You talked about cancer patients that you take care of that are also physicians, maybe physicians with disabilities, or our queer colleagues. Could you talk a little bit maybe about your own experiences as a woman of colour? And then maybe some of the patient experiences that you've seen for women who have intersecting identities?
MG: You know, I'm not entirely sure that we can separate out all these injustices that women experience from different aspects of that intersectionality. I think, though, the concept of intersectionality helps us understand that while all women are subjected to some of these challenges, there are some women that are subjected to this even more so. And I think that's really what we have to understand here. So, it’s hard to sort of, specifically tease out what comes from what area, but we just know that if there are more challenges, then you're affected even more so. I'm going to say, for me, personally, I didn't really understand that at first. I didn't really notice it. And part of it, I think, if I think about my background was we moved — my family moved from India to Canada when I was four. We grew up in a small town in Nova Scotia. My dad was there at the University, and we were, I think, one of the first non-white, non-Catholic families in town. And what was great about that was that there was no previous expectation, and so, there were actually very little biases. I am very pleased as I look back at how well we were able to integrate, and how open our family was to having our neighbours and our friends come over and understand our customs and our culture. So, there was a real sharing, and a real getting to know and understand each other. But there was this, as I look back, also a sense of fitting in. And that was really how we managed that we fit in; we fit into the small town that we were kind of the only one that was different, the only family that was different.
I remember and, I think most people do, young girls fitting in, in high school. That's a whole other story. But fitting in, in medical school — I think there were two of us that were visibly women of colour in my class, and I was still motivated by that sense of "I'm just glad to be here," happy to have this opportunity, and I'm going to do my best to succeed. And part of that was by fitting in, and so, honestly, for me, the whole concept of the racial bias, being a woman of colour, didn't actually come home until after I had a meeting with a preceptor in my psychiatry residence. So, fairly, fairly further along, and at the end of our rotation, we were getting together to complete the evaluation, and that was when he first disclosed to me that he didn't know what to think when he first saw me, and what he expected was that this was going to be a horrible rotation, and that I wouldn't know anything — I would have, I don't know, an accent, I wouldn't be able to speak to patients, I wouldn't be able to understand, and that, in fact, I had exceeded his expectations. And while I guess that's positive feedback, it really got me thinking about what expectations did he have? And why did he have those expectations? And I think that really opened my eyes to understanding that even though I hadn't noticed or hadn't been looking for this, those expectations are there, and they do motivate people's behaviour, even within the medical workplace.
SS: Thank you, Mamta, for speaking so eloquently to what we now I think better understand as assimilation, and often what people of colour have to do to assimilate into community, which is not always a negative thing, but sometimes we don't realize that it's happening, as you say, until we look back. And also, I think those implicit biases that we all hold about one another, which your preceptor actually then communicated to you, and it's so interesting, as you found out, to realize that somebody is holding these implicit assumptions about you without even knowing you. So, thanks for sharing that story. I think that's a really powerful story, illustrating how implicit bias plays out for all of us. We all hold that in some ways.
So, I want to just move on to sort of the last few questions that we have here for you, which I think you've touched upon a little bit already. And I actually remember, I came to a "Women in Leadership" course that you ran, which was really transformational for me, and you talked about the sharing of privilege, and you were speaking actually about your boys. You have two sons in medicine, as you mentioned earlier in the interview, and you mentioned that you have actually said to them very overtly, that as men in medicine, you have to share your privilege. I wonder if you could talk a little bit about what you mean by that. Maybe give some examples. Talk a little bit about what you want people to know, in terms of how do you be a good ally to a woman in medicine.
MG: Yeah, thank you. I think allyship is so important, and I want to take a moment to appreciate and recognize the male colleagues that have been amazing allies to me throughout my journey in medicine, and in the work that I do with physician health and physician leadership. So, it's a topic of conversation around our dinner table. We talk about experiences that happen on a day-to-day basis, and, sometimes, what's disclosed to me by our women colleagues, but also what I've experienced personally. And my husband, who's also a physician, and my children have heard many times that there are things that have happened where, for example, as women physicians were mistaken for the nurse. So, you walk into a room and a patient asks you to grab the bedpan. Now again, not that we would mind helping out a patient, but the assumption is that we couldn't possibly be a physician… Would talk about going to speak at an international meeting, and I'm part of a panel and I'm the only woman on this panel. And, you know, the introduction goes, it's "Dr. So-and-so, who's an expert and blah, blah, blah, and Dr. So-and-so, and Dr. So-and-so, and Mamta in the red jacket." Right? And so, if that were my qualification for being on this panel. I think that, and again, you think about in the workplace, that being called by your first name, versus everybody else is a physician, and these are things that my boys have been very sensitized to.
And then I remember in their own residency, actually, even before that, in their own medical school training, they started to come home with stories or share those stories with me. And there were many, many versions of, or variations of a story, like, "You know, mom, I walked into the patient's room with my attending who really is the expert in this area, she's known internationally, and because I am tall, I'm a male, the patient automatically looks to me as the expert." And so, we talked about that. So, that's going to happen, right? You are a tall, slim, attractive man, people are going to notice you. That gives you some privilege, and the important thing is to share that privilege. And so, they have been really great at just bringing it back and introducing the female attending they're with as not just her name — and she is the specialist, but she's actually a world expert in whatever that area is and that assuring the patients that they're in good hands. And to say, "I am the medical student and I'm going to learn a lot from her and from you in this conversation." And I think that this is just how they walk into the hospital recognizing that their gender, their bearing, just being tall, to take up a bit more space. That again, gives them a certain amount of privilege, and that leads to assumptions that they will — they can't sort of necessarily change, but they can make sure are not inappropriate or certainly are shared.
SS: And I know that you talk a lot about, and have actually created communities, where women in medicine can support one another. I know you talked earlier about how these micro-aggressions or even macro-aggressions don't always necessarily come from men towards women in medicine, there can be some of that that happens internally or from other female members of the healthcare team.
So, I'd love to hear just a little bit about, and I think you've talked about this already, but maybe a little bit more about what really inspired you to create those communities, which I know personally, for me, have been really powerful in my career, and you've actually invited me to talk at one of those communities recently, as well. So, what was it? Was there a moment or was there something that made you think we need to support one another, we need to come together? What was it that lead you to doing that work?
MG: Yeah, well, I'll tell you, one of the biggest things is my own personal experience. I am one of five sisters, and I have to tell you, when my sisters all get together, that's my happy place. And I really experienced that sense of having people that understand you, having people that perhaps have experienced that before. So, I'm in the middle, actually, of the five. And so, there are sisters who have perhaps done some of what I'm trying to do in the past and are able to share some of their experiences, and guide and mentor me. I have younger sisters that are very creative, or very innovative, and are able to add to the conversation or add to my thinking, or that I can bounce ideas off. And I just see how great it is to be in a room full of people, of women, that support you, and it's a different way — and I realized how important that is, for me personally, and then started to think about how I have over time created small groups of support of supportive women in my own professional life, as well. And whether that's groups of women in psychiatry, groups of women in other specialties — I must say, I have been involved in the launch of about eighteen different groups of women in a certain subspecialty, which has been so wonderful for me. And I see how important that is and I think there is value to sharing some common challenges, sharing some common goals, sharing some common experiences, but then there's also value from getting input from somebody who isn't part of that scenario, and can give you that outside perspective as well. I see that happening in my home and I wondered, wouldn't that be great to have that for women in medicine. And so, part of it is just seeing how important that is; for me, seeing as other women experienced it, what a difference it's made to their level of confidence, their ability to take on a leadership role, and to shine in it because there they have a network that you reach out to, that supports them along the way.
And I think there are so many things that we all find interesting, that we find ourselves busy with — this happens to all of us, right? That, because we like so many things, we start to realize at different points in our life, I have a lot on-the-go — how do I pare down? And to me, I think that's happened, and just because you know that doesn't mean you do it perfectly — or that you do it once and then you you're done. So, I've probably had to do that about three or four times in my own professional life as things kind of build up again, to think, "Okay, you know, for some reason, I've got a lot on my plate again. What do I have to look at?" And so, more recently, as I was doing that the last time, just before the pandemic started actually, I remember thinking, “Okay, maybe I have to just look at everything I have on my plate and think about these, when I do all of this, which is the one that I'm the happiest doing.” And for me, it really has been my work with developing women colleagues and women leaders in medicine, and so that became sort of my area of focus. I feel like it's so important to support that development of women leaders, and it's something I really get a lot of joy and satisfaction out of.
SS: That's great, Mamta. That importance of community and sharing stories is just such a crucial part of what you're talking about, and you really have helped so many of your colleagues, not just with the burnout, and being a psychiatrist and clinically, but through this leadership development. I know personally, I can attest to that as well. I have one last question. You mentioned the pandemic and how you were sort of crystallizing, before the pandemic, some of the direction you wanted to go in. Can you speak specifically as a psychiatrist, and particularly as an expert in physician health, about what you have seen to be some of the effects of this pandemic on physician wellness, physician burnout? We knew that that was a problem even prior to the pandemic. What have you seen happen now that we're two years plus into this with physician health?
MG: Thank you for the opportunity to reflect on that. I have been very privileged to have had conversations with many physicians across Canada and the US throughout this pandemic, and I credit them with what I'm going to share with you, but really, I've seen a really amazing impact and perhaps not unexpected. As you've said, even before the pandemic, we had high rates of burnout. We were looking at about 1 in 2 physicians experiencing some signs and symptoms in keeping with burnout. And I'm actually a Chair of the OMA Burnout Task Force, and — we had actually planned a survey to Ontario Medical Association members in March of 2020, which coincidentally happened to be just as the pandemic was hitting us here in Ontario, and the results of that showed about 66 percent of physicians experiencing symptoms in keeping with burnout. So, we'd already gone from 50 percent to 66 percent, just knowing that the pandemic was happening, and we were kind of in the middle of that very first wave. And we repeated that a year later in March of 2021, and we saw the numbers go up to almost 73 percent. And as early as, I think, May of 2020, the WHO had done some studies on the impact on mental health of health care workers in multiple countries around the world, and we're just seeing soaring rates of anxiety, depression, insomnia, PTSD. So, we knew even early on that this is going to impact mental health. So, we really see the increase in burnout.
A couple of other things that I'm hearing about is compassion fatigue. Compassion fatigue can be related to burnout, but it's different. Where burnout is more about system level factors and the amount of workload and having to manage that, compassion fatigue is that fatigue that we have where we can't basically recharge. And it's not so much all the compassion we're giving to people that is draining, but it's really mirroring the distress of people around us, and sort of absorbing that trauma from our patients, from our peers, from our family, which many of us have been exposed to throughout this pandemic. And what happens is that we just can't re-energize. We can't get refilled to be able to do it again, and we're fatigued. We're drained as a result of that.
I'm also seeing and hearing stories about moral distress. Moral distress is that distress that we feel when we know what we would like to offer to patients, and there's a block, there's a system level factor that prevents us from doing that. And that again, hits us at a very emotional, very moral level. Perhaps getting care that's not entirely in keeping with our own values, and again, we're seeing studies that show 70 percent of physicians throughout this pandemic are experiencing moral distress when they're dealing with a double bind of, do I do what's best for my patient? Or do I do what's available in the healthcare system or in this hospital or what I'm being asked to do now? And again, we had a lot of this experiencing before the pandemic, but it really has intensified as we've made some difficult decisions about who do we see virtually versus in person. Who do we see? Who do we send to the emergency room? Who gets admitted to hospital? Who gets admitted to the ICU? Who gets surgery? These are all very difficult decisions that lead to moral distress. We get enough moral distress, we start to experience moral injury, and I certainly am hearing about that.
The other thing throughout the pandemic has been the sense of grief. We have lost so much, so much of what was normal, of a sense of control. Some of us have experienced economic loss. We've lost a sense of connection, and we've talked today about how important connection is, and that one of the more important things that many of us reach out to, to stay well, has been limited and restricted to us throughout this pandemic, and so we're grieving, and we're in different stages of grieving, and throughout the pandemic. And it's multiple phases, what we're seeing is that we're going through those stages of grieving further. We're going through different stages and different levels of intensity, and I see it different times, where we come out of denial, and we're into anger and protest. And I'm seeing that none of us are at our best. We can be more irritable, we can be more easily frustrated, or more critical or more cynical, and we're seeing that. Early on in the pandemic, there was a real sense of solidarity, and we were going to get through this together, and we were going to help each other, and now we think we were drained. And there's a sense of, we're just trying to get through, and that's really all the energy we have, and sometimes we're not even doing that really well, and we can start to see that sense of irritability and frustration comes through in the workplace. And we're experiencing it, but everybody we're working with is experiencing it as well.
I also want to just add that this has not been an equal opportunity pandemic, right? So again, our women colleagues have been, I would say, more impacted than our male colleagues. And we see this, again, just in terms of the personal responsibilities. Women are doing a lot of homeschooling, are now not just a parent, but you're a teacher, and the IT tech and your kids' social support, which is really hard to do, especially when you're working from home as well. I think we see in the hospital and in the academic settings that women have been, from the very beginning, asked to do some of these more citizenship tasks. Some of these things like, "Can you support the medical students and residents?" "Can you write the patient brochure, pamphlets?" "Can you procure PPE?" All of which takes a lot of time, takes a lot of energy, but again, it's not recognized, if you think about traditional promotion pathways. And I think that what we also see is that throughout this time, women have been busy doing things, and our male colleagues have taken the opportunity to be more productive academically. And I think it's a real opportunity here. We talked about allies before. I think the most important thing for allies is to recognize that inequities exist. I think that they can make an impact if they acknowledge and speak out against them, and support their women colleagues in medicine.
SS: I love how you're offering some really tangible ways in there, Mamta, for allies to come forward. Can we think about promotion and tenure differently? Can we think about what is rewarded, whether that's paying people for the time to do the PPE procurement or recognizing that in some other way? Can we think about flexibility for people who are trying to homeschool their children? Can we think about flexibility for people who are trying to care for elderly parents, perhaps, or elderly relatives on the other side of that spectrum?
MG: Yes.
SS: And I think also what you said about allyship there, in that I learned this from a fellow academic researcher who examines privilege. Her name is Dr. [Stephanie] Nixon. And she talks a lot about from whom words are coming, and from whose body those words are coming can land very differently. So, it may be that as women in medicine, we say something, and it doesn't land in the way that it may land if one of our senior male colleagues says the same thing. And so, I think you've also talked about that in some of your leadership courses, how do we amplify each other's voices and how, as an ally, can you amplify maybe what some of your women colleagues are saying? How can you tangibly support that in a very practical way. So, one of the things we wanted to also ask you about as an expert in physician health is when physicians are unwell, when they're starting to get burnt out, or even more so as you're saying, experiencing moral distress, moral injury, how does that affect patient care? How does that affect them doing their work, which is taking care of patients?
MG: That's such a great question, because physician wellness is really the foundation of medicine, that physicians need to be supported to be as well as they can be, so they can put their time and energy into taking care of others. So, we've seen physician burnout impact in the healthcare system at multiple levels, obviously, impacting the physician. We've spoken a little bit about that, impacting our patients and impacting the system. Specifically, about the patients, I think it impacts in two main ways. The first is quality of care. We are seeing some studies that show that physicians who are experiencing burnout are not able to perhaps be as focused or pay as much attention. We do see an impact in patient safety, in quality of care, with things such as increased rates of medical errors. We see sometimes a change in people's prescribing patterns, sometimes perhaps a little bit riskier or less thoughtful. We see less connection and engagement of the patient, so then, less adherence to management or the care plans that we've laid out for our patients. So, the quality of care certainly is impacted, but the other thing that I think is impacted is the quality of caring. What we see is, again, we're exhausted, we're drained, and so our ability to have our usual, our previous level of effective communication, the quality of that communication, the empathy that we would show our patients, the ability to engage our patients in a way that we would do previously when we are healthy [is diminished], and of course, impacting our patient satisfaction as well.
SS: Great, thank you. Those are all really, really important things for us to think about as physicians, and as patients. And as the regulator too.
MG: Thank you so much for having me speak with you today. I really appreciate the effort to have this recording, this conversation, but I also appreciate the focus for the CPSO on physician wellness and supporting physicians as they do their excellent care of taking care of the patients of Ontario. Thank you very much.
SS: And thank you, Mamta. Thank you for your time today.
Closing
Thank you for joining us. Please visit CPSO Dialogue for more in-depth discussions about health care. www.cpsodialogue.ca
