E19 Jane Lemaire on Burnout, Resiliency and Coping during COVID

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Ameer Farooq  00:15

Welcome to Cold Steel, the Canadian Journal of surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons, we hope you enjoy it.

Chad Ball  00:50

Dr. Jane Lemaire is an internist at the University of Calgary and is a national expert on the topic of physician wellness. In our conversation, we talked about physician burnout, resilience, and some strategies to help us cope during these incredibly challenging times. Please take a look at the show notes for links to the papers and resources that we talked about in the podcast.

Ameer Farooq  01:10

We wanted to start by asking you, since you’re the first non surgeon on this podcast, could you tell us a little bit about yourself? Where you did your training where you currently practice?

Jane Lemaire  01:23

Sure, well, I’m honored if I’m the first non surgeon to be on the podcast. Thanks for the welcome the warm welcome. I actually trained at the University of Ottawa a long, long, long time ago, and then did my internal medicine training in the United States at the University of Washington, and then moved to Calgary and have been here since 1991. I am a clinical professor of medicine, I continue to practice in general internal medicine as a consultant, mostly at the Foothills Medical Center. And I’ve had a long and varied career, mostly doing medical education early on. And then for the last 15 years or so, I’ve been doing physician wellness and have varied titles related to that job.

Ameer Farooq  02:13

You know, I read a fantastic interview that I think you did with the CMA where you talked about how you got interested in physician burnout. And I think for our listeners, it’s important to note that you’ve really become a national leader on the topic within Canada, and for sure, locally, can you tell us about how you got interested in the topic of physician burnout? It was kind of serendipitous, really, we had a very visionary chair in our Department of Medicine, who, back in 2004 noted that there were more women graduating from medical school and thought that we should do something to adapt to acknowledge and and welcome that. So he asked me if I would become one of the vice chairs of the Department of Medicine, around gender issues. And at the time, I spoke with him and said, Why don’t we really get ahead of the curve and make this about people about our physicians as our most valuable assets? And could we do physician wellness, instead, recognizing that within the field of physician wellness, there are gender issues, there are generational issues, there are practice style issues, there are different personality issues. And he was really willing to go there. And so we started off on this adventure together. I had the first to our knowledge, the first formal appointment as a physician wellness officer within a Department of Medicine across the country. There were positions at the time at the UME offices and the PG&E offices but none within the system, quote unquote, for staff doctors. And there was a big learning curve for me. And that’s been absolutely wonderful to do this over the last 15 years.

Chad Ball  04:10

Dr. Lemaire, I guess physician wellness and physician burnout are maybe two ends of the same spectrum for sure. They’re certainly related, of course, just curious how you define each of those terms formally. And how big of an issue is the ladder in Canada.

Jane Lemaire  04:30

So the whole issue of burnout versus physician wellness is really important. So burnout has been defined as work related hazard. It’s basically an occupational hazard for physicians and also for many people who do work where they take care of other people. So teachers, social workers, have high burnout rates as well. But we started to understand that it was a risk factor for physicians. It’s been extensively studied now for decades. So it’s a formal construct. It has domains, the three main domains are that of emotional exhaustion, cynicism, or depersonalization, where you start, having those inside voices that maybe aren’t so nice. And then personal inefficacy. So this idea that you’re on this treadmill and no matter how hard you work, you just can’t get ahead. So the idea of burnout has been really well studied. But one of the issues is that people define burnout and measure it in different ways. And that’s created a lot of controversy, and a lot of challenges in being able to measure burnout, across countries across different populations, etc. What we do know about burnout in Canada, the latest study from the Canadian Medical Association, they did a physician health survey in 2018. The burnout rates as they measured them, were about 30% overall in our physicians. They had an 8.5% response rate across the country, males were underrepresented and some of our Northwest Territories, Nunavut, etc, were not well represented, so just to qualify that. What they did show was that our physicians are really resilient. So 82% of them said that self reportedly they were very resilient and have high levels of emotional well being. And 30% demonstrated burnout in the measures that they used. If we look at that, compared to the United States, I think the best data we have south of the border, the higher response rates, etc,  Take shanafelt in his group have been measuring burnout in physicians, first in 2011, then in 2014 and then in 2017. So he has longitudinal data and their numbers are higher. Their mean burnout rates are around 48% for their physician population, in 2014, they got a little bit better and in 2017, sorry, in 2014, they got a little bit worse and now in 2017, they’re looking a little bit better. But definitely the way they measure burnout or because of the healthcare system and the way their physicians work, their burnout rates are higher.

Chad Ball  07:37

There’s a ton to unpack there. And, I think hearing those statistics is very sobering, especially the first time you hear it. But for the maybe the more cynical amongst us, does it matter that so many people are experiencing burnout, so many physicians are experiencing burnout? You wrote a paper that was published in The Lancet talking about physician wellness as a missing quality indicator in health systems. Like, why is that such a big deal? For a health system?

Jane Lemaire  08:15

I think that’s a really great question. And early on, in the whole world of physician wellness or physician health, we really focused just on people who were crashing and burning. So people who are suffering with substance use disorder, the quote, unquote, you know, disrupt the physician. And then we started to recognize that burnout was more of an occupational hazard. So you might, if you were a fireman and I was asking you, does it really matter that some of you are burning, like literally, you know, suffering from death in your workplace? You would say? That’s a big deal. So in our Lancet paper, we did a narrative review of the literature, Dr. Jean Wallace was the first author, Dr. William Galley, the senior author. We recognized that people were physicians were at risk of being unwell and that manifested his burnout, and that when they’re unwell, they suffer. So they suffer personally. There are many, many effects of being burned out. And then we started to also recognize that when physicians were not well, they negatively impacted the healthcare systems in which they worked. So the physicians themselves were suffering personal consequences, including poor mental health, suicidal ideation, substance use disorder, patient care was affected. And then the health systems that they work in, were also being affected. So it is important. There’s also a financial cost because sometimes the bottom dollar is unfortunately what we listen to as the most important thing in the Annals of Internal Medicine last year, they published a paper showing that the cost of burnout to the US health system every year was in the range of $4.6 billion, about $7,000 per physician per year. And that cost was through things like decreasing their work, leaving the practice. Then there was cost of unnecessary tests, physicians, sorry, patients, going to other physicians, because the care they received wasn’t very good, because the physicians were burned out. So is it important? Absolutely. It’s important to the people within the workplace, our moral duty to physicians and their profession, it’s important because it absolutely influences our ability to deliver quality care. And then it costs our healthcare system. So in our lines of paper, we propose that it was a missing quality indicator that we should be measuring physician wellness, because it influences health care systems to that extent.

Chad Ball  11:13

Wow. There’s obviously a multitude and a great breadth of factors that probably contribute substantially and significantly to physician burnout. What are some of the things that really stand out as an impressive risk factors to you? And I’m curious, in terms of risk mitigation, or prophylaxis, or intervening, where do we go?

Jane Lemaire  11:38

Well, that’s a jam packed question. I think, again, to be clear that burnout is a formal construct that’s been extensively studied. Christina Maslach, the person who’s done most of the work, but many others have contributed. So burnout happens whenever you have a mismatch between the person and the job, because I told you, it’s not an inherent weakness in any of us. It’s a job related hazards. So if there’s a mismatch between you and your job in terms of workload, control of your workplace, the rewards that you feel within your job, the sense of community or how your community acts, a sense of fairness within your work or the organization that you work with, or a sense of values. If there’s a mismatch between any of those things, those are the foundational drivers of burnout. So you can just think, as we’re going through that list, if that happens to us all the time and we have those mismatches, right? In particular, for trainees for resident physician, you have huge workloads, and no control and that’s one of the reasons that we understand that you’re at the highest risk of burnout of any stage of your career. So those areas of mismatch, create our foundation. So then you have the drivers. And so if you think about it, they’re mostly work related drivers. So things like your workload, the demands of your job, the ability to have control or to have any flexibility in your work. How about efficiency, and the resources? So in particular, for you all, as surgeons, you don’t always have control over the resources that you need to do your work. The ability to integrate your work and your life. In all the studies of burnout, one thing that really stands out for surgeons is that they have very, very low work life balance, very little time for their personal life. That comes out in most studies on both sides of the border. The organizational, the culture and the values within the organization. Those can also be driver dimensions. And if any of those things aren’t going well, you’ll develop more burnout, more exhaustion, more cynicism and more in efficacy. If you don’t have the resources, you need to be efficient and you can’t get the work done. You’ll have moral distress, and you’ll also be inefficient and you’re going to be mad about it. And that all adds to your burnout.

Chad Ball  14:26

As you talk about these things, I’m thinking about various phases of my life during residency and it’s interesting being now fifth year and looking back in it and actually, now that we’re sort of off and not being in the hospital to do this whole COVID business, it really kind of gives you perspective as to what you were like, even a few months ago, and what you we’re like now, you’re sort of alluding to some of the differences perhaps, or maybe similarities in the way that surgeons experience burnout compared to other physicians Do you have any insights as to what are some differences in the way that surgeons experienced burnout. And what surgeons potentially could do about that?

Jane Lemaire  15:18

So overall surgeons, drivers of burnout are pretty much the same as anyone else. There are individual factors. So just our personality types, for example, they may put us at increased risk of burnout. We tend to have obsessive compulsive traits, we tend to have perfectionistic traits. surgeons in particular, have perfectionistic traits. And those are associated with good things like we want to have surgeons who are really worried about how things are going. But also perfectionism is associated with a higher risk of suicide, for example. Then there are factors within our culture. So we have a culture of medicine, and then each of our sub specialties or specialties have cultures. So there’s a surgical culture. Then there’s the health system that we work in. So those are all where the drivers lie for surgeons, in particular, the work home conflicts, excessive workloads with most physicians on the front lines, experience and put people in hospital settings, they tend to have higher burnout related to that. Surgeons quoted in a study from the United States inadequate time for their administrative tasks, no personal time, the length of their work hours, the number of nights on call and then again, the word comb conflicts have been really important drivers for them of burnout. In the study from the CMA, they looked at burnout in terms of specialty to see if there were any differences. And the surgeons demonstrated a statistically significant difference compared with other specialties and trends of emotional well being. They had the lowest sense of emotional well being of all compared to the other specialties. They also had, although not statistically significant, their numbers were highest for suicide ideation, lower social wellbeing, lower psycho psychological well being, and they burn out right for slightly higher performers.

Chad Ball  17:34

I would think that certainly COVID right now would add a whole different dimension to stress and maybe potentially a physician burnout, I don’t know. But it was the clinical component of it. There’s a financial component of it, there’s a family component of it, all those sorts of things. How do you think COVID in particular has impacted physician well being? And do you think it will impact physician burnout or not?

Jane Lemaire  18:01

I think that’s such an important question. I’ve actually been on our pandemic Planning Committee for the Calgary zone, informing as to physician wellness. I don’t think we know. I’ve been practicing medicine for almost 40 years, and we’ve never experienced anything like this. So it’s pretty new. I think we can say with certainty that this is, not about burnout. Burnout is a really different,  construct about occupational exposure over time. What we’re seeing is a threat to wellness, mostly, because of the fact that this is a crisis. ,We are seeing a lot of anxiety, we’re seeing a lot of fear for personal safety. We’re seeing some things that are typical to any big crisis, which is mourning the loss of our normalcy in our life, uncertainty, the financial uncertainty, the uncertainty over our health, the health of our loved ones, our ability to do our job. And then just that lack of control that goes along with the uncertainty. We’re seeing huge increases in psychological stress for people in general and for physicians. The added stressors and anxiety of the risk to their personal safety and to their families as well. We’re also seeing very big because there’s such a gender and generational shift in medicine. We’re seeing a lot more work family conflict right now. Because female gendered physicians, and then the younger generation of male physicians who are more active participants in childcare are in the home duties, are being stretched to the max because the children are at home. So that’s creating also some increased challenges in terms of trying to continue on with life as normal, when nothing is normal, when we’re all functioning at less than our best.  When we’re all feeling irritable and stressed, not sleeping well. And then we have these added challenges of having to make sure we’re caring for the people around us. In terms of whether this will affect our burnout, someone asked us if we were going to measure burnout during the pandemic and I was like, I don’t think it’s the right tool. I really don’t. I think we’re looking at acute psychological decompensation due to very real stressors. I think things will settle out, and we’ll have a new normal. If we go back to work in exactly the same way we did before, we’ll see burnout, because I don’t think anything about the pandemic is going to make it go away. I think people’s depleted psychological reserves will likely increase their burnout over the long run. But we’re not sure about that.

Ameer Farooq  21:01

I couldn’t agree with you more about this being just a completely crazy time. I’m currently doing this podcast from my car because my children are up at home and I don’t want to go to the hospital. And there’s nowhere else for me to record. So here I am.

Jane Lemaire  21:17

Well, I wanted to circle back to something that you said about how you’re having an epiphany or some insight about what life is when we’re not in the very busyness of our profession, as physicians. And I think that surgeons in particular are very focused and you have to be able to push through when you’re in the operating room when things may not be going well. Early on, not sure of the year, however, a study out of the United States looked at burnout in surgeons. They actually asked surgeons to rate their well being compared to their peers nationally and 90% of the surgeons rated their well being as average or above average compared to other doctors across the nation. Then they objective tested those physicians and 70% of them scored in the bottom third. So the big takeaway message was that there was this perhaps inability to calibrate our distress so that when we’re in the thick of our careers and we’re working so hard, we use lots of different coping strategies and denial and avoidance are an effective coping strategies, strategy for a lot of people. The takeaway from the study that the surgeon felt so unwell day to day that they calibrated that to like that was normal. But then when they compared them to other physicians across the nation, they were really, quite low well being by objective measures.

Chad Ball  21:37

I don’t know that I would characterize myself as being burnt out during residency. But for sure, you don’t notice certain things. You don’t notice how tired you are for sure. Then a couple of weeks where you sleep, sort of semi regular hours, you start to notice how different you feel for sure, so I couldn’t agree with you more there. But it’s so interesting that perhaps maybe as surgeons, we do build certain mentalities. I don’t know, is that resilience? Or is resilience something completely different?

Jane Lemaire  24:02

I think that’s a really good question, right? Because medicine is not the same for everyone. If you’re a family physician working part time versus a surgeon versus an in hospital specialist versus primarily outpatient specialists, your experiences are going to be very different, your lived experiences are going to be very different. And then also your social circumstances that are going to influence things as well. So for example, if you have lots of help at home, and you can focus on your career, that’s very different than someone who’s trying to juggle both a career and a lot of work at home. So resilience, if we want to talk about resilience strategies, there’s some science around that as well. We generally characterize resilience as you know, the ability to weather through tough times, to have some buoyancy, the ability to bounce back, and then often to find meaning during those tough times so that you learn and you grow as an individual. There’s been some studies done to characterize what are resilient strategies that physicians who are doing well seem to rely on. In the general literature, there’s not a lot of literature on this that I, that I know of there may be some out there for surgeons in particular. But it’s really about a few things. The first is receiving gratification from your work. So, I’m an internist. So if I get the diagnosis, right, and, you know, we’re like, who, we figured this one out, we’re being detective. And for you, as surgeons, I’m sure it’s, you know, being skillful in your work. So our medical efficacy gives us gratification and that makes us more resilient. It actually helps build our resilience. Cultivating our relationships with our colleagues and our families and friends. Every study ever done that looks at collegial support and support from friends and family, shows that it buffers you against burnout, there’s no doubt about it. That’s why we try to have peer support teams when we can, having ritualized time outs and leisure time activities, so carving out that time for yourself, where you’re not working, where you’re not on your email, there’s a whole science around restoration. So a restoration can be a little 10 minute timeout during the day, it can be a holiday, it can be a sabbatical, it can be a weekend without work, but you have to have that self awareness, understanding who you are, what you can do, and working with that. Then optimism and positivity. People sometimes joke that you can be all Pollyanna ish, I don’t know if that’s a word. But you know, sort of the perky happy person all the time. But there’s very good science in the psychological literature, that just appreciating the good things and being an optimist, really allows you to experience your life framed in that positivity and optimism. You don’t suffer as much as if you don’t do that. There’s some science in the physician literature that shows that doing that buffers you against burnout.

Chad Ball  27:19

I have a two part question to follow up on that. The first is do you think that there’s a significant or relevant generational difference in resilience? The second question that is sort of surrounds how we train folks. We wrote a paper quite a while ago, comparing how we train astronauts with how we train surgeons. That concept of surgical and technical training, comes up in various different to be raised different filters over and over again. Of course, whether that’s work hour restrictions, appropriate sleep and rest, and many of the concepts you’re talking about, when we think about how we train some of these, elite groups, Special Forces groups, navy seals, again, astronauts, the training paradigms are all over the place. But my overriding observation or belief is that we don’t train it well, within the surgical culture. Do you have any thoughts on those two?

Jane Lemaire  28:16

Sure, so in terms of the generational differences in burnout, there’s actually pretty good science that shows burnout peaks when you’re in your residency training, because of the things we talked about; no control, high workloads, no flexibility. You can’t adapt your life. Then the first five years of practice, our vulnerability period. We could talk about that for a huge, long time. We all go through this imposter phenomenon, we have to take on the sort of ultimate responsibility for patient care. We’re learning. No one is 100% skilled at their job, when they started experiences something that makes us better and makes us more confident, makes us more effective and more efficient. So the first five years, we see burnout there. As you go along in your career on average, most people have less burnout as they get older. We’re not 100% sure whether that’s because you get more comfortable in French, we say on est bien dans notre peau which means you’re good in your skin, you feel good in yourself, right? And it’s all that wisdom, experience and so on, or whether part of it is attrition. So people who are not able to survive for a lot of factors. They don’t make it to a later stage in their career. So there are some gender, some generational differences, and I think the gender shift in medicine is going to have a huge impact as it should. I just want to make a point that I haven’t been able to make that is 100% important and critical to the science of burnout. I said there were individual factors, there were things within our culture of medicine, some very toxic things in our culture that actually support burnout. Then our health systems don’t necessarily provide us with the things we need. Often just the way the system works contributes to our work, our burnout. At this time now in 2020, the science of burnout suggests that over 80% of the drivers of burnout are at the system level and within our profession. So want to make that 100% clear for everybody out there that might be feeling burned out. In the early years, we just said, we have to get tougher, we have to have more, that term grit, you have to get stronger, you you’re not cutting it so you just have to train harder. But the science has proven unequivocally, that the drivers of burnout are coming from the system. It’s that canary in a coal mine analogy that you can be the toughest, strongest, trained athlete, astronauts but if you get out into space, and one of your systems isn’t working properly or there’s a glitch or you’re not supported, it’s not going to work. I just wanted to make that point. That’s where the science of burnout is that. In the early years, we blamed us for not being resilient enough. Now we realize there are systems level drivers that are hugely important. That doesn’t mean that we shouldn’t work on our personal resilience. We’re not throwing that proverbial baby out with the bathwater. I was going to talk about the idea of resilience training, it’s important for us to be sure that when you come into medicine, that you’re able to tolerate the psychological stressors of our career. I heard you making an analogy to astronauts and you know, athletes, and it’s true,  if you aren’t able to deal with the psychological stressors of a career, you’re not going to succeed as a physician, just like, if I wanted to be a ballet dancer and I didn’t have any flexibility. I couldn’t have those skills, it’s not going to work. So I think we have to consider that we have to be able to prepare people for the stresses of the career. As surgeons, I’m not a surgeon so I can’t speak to your lived experience but I’m hearing you say and on reading your paper that you know, there are times when the going gets tough, and you have to be able to deal with it, you can’t walk away. So I do believe that for all of us, I can’t walk away when I’m in the middle of quoting a patient, when we’re on our 10th, or 12th, or 15th hour and our brains aren’t working anymore, we still have to face what’s happening in front of us. We do have to have some tools that help us cope with those situations within our work that are absolutely critical to the profession. You can’t be a physician unless you can get through those times. So in terms of training, I was interested to read in your paper that a lot of the tools that the surgeons used to get through some of the challenging times were things like slowing down, reframing, applying some mindfulness techniques, deep breathing, visualization, talking to themselves, having optimism that things were going better, and so on. I think it comes down to performance under pressure and having some tools to have that readiness to perform under pressure. In the in the sense of that context. I think that we all should be taught those skills. This is just my personal belief. I believe that sometimes when we just start talking about breathing and mindfulness and so on, people say that’s pretty touchy feely and in I’m not going to go there. In fact, these are performance techniques that people in the military use, people athletes use, astronauts use and I’m hearing that surgeons use those techniques as ways of getting through. What I think is most important is that we explore that science. We find out from a surgeon perspective, what are the things that you do use and then start teaching them and what you want to call them. It comes down to a bit of a culture, right? I don’t know what term you want to use, but we talk about being performing under pressure. Having a readiness to be able to deal with what is in front of us.

Chad Ball  35:19

That’s so well said. Not too long ago, we interviewed Scott Gomorrah, I don’t know if you remember him, he was a resident in my era that came through Calgary as well and general surgery side of things. He was talking about one of his friends who’s a very, very well known famous female golfer, on the LPGA Tour. When they were initially started hanging out, she was asking him a bunch of questions about how he was trained and taking time out and mentally framing what he does and dealing with stress and he really had no answers for her in terms of how we did or didn’t do it. She had exactly l a long history of really deep psychological coaching, in addition to the physical coaching, in terms of being in the moment, and just so many tools that she had in her tool belt. The discussion and the dichotomy in those two scenarios, both, I would say highly trained professionals was so different. So I don’t think we do it very well in surgery at all.

Jane Lemaire  36:24

I think it’s such an interesting area to explore. That’s a very important one. Because when I read your paper, I was really intrigued to hear the descriptions that the surgeons gave us of the tools that they use. It really is about mental readiness, of getting yourself set up as you’re going into a situation and then practicing those tools, being able to rely on them when the time comes. We do a lot of that in our resilience training. In physician wellness, we just call it different things, we actually call it mental readiness, in some of the programs, they call it that as well.

Ameer Farooq  37:10

As a trainee, what we’re getting at and dancing around is really one of the central tensions that residents in particular are vulnerable to, which, there’s on the one side, there’s all the personal, resilient things that you need to do to try to be the best resident you can be. But then there’s there’s also the things that you were talking about in terms of the system, which sometimes feels very, particularly as a more junior resident feels like those are sort of immutable and for example, as a junior general surgery resident, holding the call pager, you have no control over the number of pages that you can get, and we easily at the Foothills hospital get over 100 pages a night holding that junior call pager. I think a lot of trainees sometimes get frustrated, not with the idea of resilience but sort of this feeling of having the onus put on them to be resilient, when there’s so many system things that feel like they’re just sort of grinding us down. How do you think trainees can sort of navigate that?

Jane Lemaire  38:28

This is such an important point, because it speaks to the fact that the trainees are working really hard and doing the best they can. But they’re still feeling, this is craziness. And it’s because there’s a culture within our profession, there is a culture within the medical education system and there is a systems level factors that make it impossible for you to succeed. It’s out of your control. It’s within the control of our profession and our system. But I think you know, how long it takes for culture change and to do change management, it takes a long time. I’ve been doing physician wellness for 15 years and in the early years, my wonderful supportive colleagues would gently smile at me and roll their eyes and say, have fun doing that touchy feely stuff. I know you’re all out there. And I really thought, okay, at least, they’re saying Hi, still. And then all we did over the years, we literally interviewed hundreds of people, we’ve followed people for hundreds of hours of ethnographic observations, we surveyed 1000s of people and then we just kept mirroring back the results. Then starting to understand that, hey, we’re all working really hard. There’s some things we need to change. I’m proud to say that now at least people around recognize that there’s a science here and it’s important. We understand the factors. So I’ll come back to your question. These things are out of your control. We absolutely have to start within the medical education system, recognizing that medicine is not the same as it was, it’s very busy, it’s very compressed, it’s very efficient. There’s so many options to talk to our patients about, there’s so many therapeutic options, so many treatment options. It’s so dense, and it’s escalated so much, that in terms of lean pipe models, I don’t think we can be any more productive or lean or efficient in the way we practice in our hospitals. So all of that means that the way I worked,  15 or 20 years ago, it’s escalated in terms of, there isn’t a moment in the day that isn’t filled with something. Your idea of getting 100 pages at night, that didn’t happen before. But now you get 100 pages at night, because we’re so efficient and effective in caring for patients and having all these people in the hospital and they’re all sick, the ones that aren’t sick go home. So the way we provide care to patients, the way our medical education system works, that needs to be revised. The Royal College put together a group of experts to really say how do we embed wellness within the training programs, and is starting to address this idea that what trainees are being asked to do isn’t feasible. But at the same time, we can’t just change and pull all the trainees out of the healthcare system, the system would collapse. So we need to make changes on the other side of things within the system about how we work. It’s intricately linked to how doctors get paid and see services and all of that. So it’s a very, very complex issue. What I can say is, we’re starting now to work with groups to identify some simple things that’s making their life difficult, and then sort of adapt a continuous quality improvement approach. So let’s take your example of 100 pages. Well, are there some things we could do so that you wouldn’t get 100 pages? Is there somehow that we could you know, lump the pages together so that once an hour you got one page from that unit and they told you the three things? Or is there some criteria for maybe doing rounds before you go on your night shift where you address some of the things like, I’m just throwing some things out there. But we know that physicians have ideas about ways to make things better. But we just never have any time or energy to implement those continuous quality improvement models that can make our lives better. So that’s, another way for us to look at it. In terms of agents of change. That’s what you are the trainees, it’s your career that is before you. We have to think about inclusion, diversity, the gender, the generational shifts, and the fact that the way we’re practicing medicine is is not sustainable. So be sure that your voices is represented that you’re asking questions that you’re offering solutions. If you see the key things that are making your life challenging, maybe pick one or two, every six months that you can try to work on collectively, with a view to improve wellness, things that don’t cost a lot of money, things that are really at the system level. I’ll give you a simple example. On our MTU, we do paracentesis all the time in our chronic liver disease patients. It was taken us 20 minutes to find the equipment to do a simple paracentesis every time, wasting 20 minutes of our day. So we finally sat down and we decided we’d have a dedicated equipment cart that someone was responsible with filling and that total frustration just disappeared and gave us an extra 20 minutes, four times a day, because we weren’t looking for equipment. So it’s the idea that we have to shift culture, it has to be in the context of who we are as physicians. So that idea of inclusion and diversity, we have to be active in our voice of those of us in medical education have to advocate for change. But we also have to recognize that it has to be in conjunction with change at the system level for the staff physicians as well and the way that we practice medicine, and it’s intricately linked as well to things like how we are remunerated and we could go on for a long time about that.

Chad Ball  44:51

There’s so many interesting things to contemplate. Maybe this is the time to do it with this COVID pause. Dr. Lemaire, if we take a little bit of a tangential run in getting close to the end here. That’s okay. One of the papers that Ameer and I love the most is your publication on nutrition for physicians. That was a chord that struck home for me personally for a couple different reasons. The first is I remember being on my sick kids rotation at University of Toronto as a medical student. And I remember someone showing me a JAMA paper at that time that looked at the biochemistry of a resident, a junior residents. I was an intern actually a group of interns at an American Center at the beginning of the shift in the end of their shift, they looked at things like sodium and creatine and a bunch of stuff that was of course, as you bring it all out of whack. The second thing is as someone who historically before my medicine, time trained professional athletes and has that knowledge, at least classic knowledge. I think I’m one of the worst offenders for nutrition and physician Karen, in the hospital, to be honest with you. So I’m curious, and hopefully you would talk about that paper and your view of it a little bit.

Jane Lemaire  46:10

Sure. So in the early days, when we were trying to introduce the idea that taking care of our wellness was actually a good thing, that would benefit us, our patients and the system. We decided we’d start with a basic which was nutrition because in all those interviews and all those surveys and observations, people often said, I just don’t have time to eat or drink. So we proposed a study where we followed 20 physicians and there were surgeons. It was at the hospital, at the Foothills Hospital. So there were surgeons, there were internist, there were some hospitalist, obstetricians etc. And we ask them to give us two similar workdays so to OR days, two clinic days to on the ward days, to research days, whatever. And then, during each of those two days, the baseline day, we ask them to eat and drink the way they usually would. Then on the intervention day, we actually fed them breakfast, good morning snack lunch, mid afternoon snack and supper if they were still around. Then we measured a whole bunch of biological things, we measured glucoses, we measured how much they ate and drank, how much weight they lost, how much they urinated, their activity levels. We had after heart monitors on them, we measured their sort of hypoglycemic, quote unquote, symptoms, and we measured their cognition. The most fascinating thing for me was when we looked at that physiological data, and also their diaries, there were several people out of the 20 that just didn’t eat or drink anything during their day. They just came into work. In particular, surgeons said they didn’t eat or drink because they didn’t want it to get in the way of their long cases, tough cases. Then they’d go home and have 5000 calories  at supper time and continue on. We had people who…

Chad Ball  48:07

Have you been following me? That sounds familiar!

Jane Lemaire  48:16

Crazy. And then there were people who had like to Tim’s double doubles, and then you know, a chocolate bar and coffee for lunch. But at the same time, we had some athletes, like some people who were triathletes and so on in our study and we were thinking, Oh, you know, they’re gonna mess up our study results, they will bring all their own food in. But when we looked at this, there was one individual in particular, who lost like a huge percent of body weight during the day, as you know, we usually put on body weight during the day, because of volume depletion. So, you talk about the military and so on. They know that if their soldiers are volume depleted, that their cognition is impaired, their decision is impaired, their emotional responses impaired. We actually had one participant who lost the percent body weight that was quoted as being significant. So anyway, this long story to say, we were astounded by the results. We felt so sad to see the way people were depriving themselves because they were too busy. There was no resources for them to step out and eat. They were almost felt shamed if they took time to say I just need to go to the bathroom or I just need to grab some food. And there was this huge sense of professionalism and duty to the patient that went before everything, even before this basic need to fuel yourself. And then in the end, our studies show that overall on the baseline day versus the intervention day, the physicians collective cognition was improved. So on the day when you didn’t eat well, your cognition was equivalent to a brain that was 10 years younger. As we all know, as you get older, your brain doesn’t work as well. So we had some sort of measures about cognition. We saw with each of the cases how much people were suffering and depriving themselves because of the system, not providing adequate food and so on, but also because of their sense of duty. So that’s that toxic culture of medicine. Lastly, they told us that when they were hungry, they were hangry. They yelled at people, they were inappropriate with colleagues, they were short with patients, they made mistakes that they totally attributed to my brain is not working, I’m going to go grab that chocolate bar.

Ameer Farooq  50:55

Dr. Lemaire, this has been such an important conversation for all of our listeners and I feel like we could have you on the podcast and talk for hours about so many different dimensions on this topic. But I think, sort of in closing, I think one really important topic that we again, have danced around but not really talked about is how can we, at all levels, whether we’re medic, medical students or junior trainees or our fives or junior and senior colleague of faculty. What do we do to protect ourselves in this very stressful time? And do you have any strategies for people going forward?

Jane Lemaire  51:42

So the first thing I want to tell you is that if you’re not feeling normal, that’s normal. Well, dark Alberta is our education and prevention provincial program. It’s a COOP, all the people who do wellness, join together and create resources. We sent out some Twitters oh my gosh, now I’m really telling my age, we sent out some tweets asking people to tell us, fill out a little survey about how they feel. And the feelings that came back are; I’m scared, I’m discouraged, I’m exhausted, I’m cynical, but then there was also I’m hopeful, I’m feeling resilient. I’m feeling grateful. But there’s absolutely no doubt that the majority of the feelings were negative feelings around anxiety and fear. So if you feeling that it’s okay, if you’re not performing at your best right now, that’s okay. Nobody is. We all have more irritability, we have less cognitive reserve, our brains are in crisis mode and they are really not able to focus the way we typically do. So that’s the first message I want to tell people. You’re not feeling normal and that’s okay. We have to have some compassion for ourselves and our leaders need to understand that we may not be able to deliver the way that we typically do. The second thing I’ll say, is our physical distancing doesn’t mean that we have to distance ourselves emotionally. I told you that every study ever done shows that if we reach out to peers and family and friends, and we talk with people, it makes us feel better. So make sure that you emotionally connect with people. Select who you talk to. If you’re going to talk to someone who’s all doom and gloom, that’s not going to help you. I’ve literally walked away from conversations and said, I’m sorry, I can’t participate. I’m just getting more stressed out. I love you guys but Bye bye, right. So pick the people that you can have good conversations with and it’s okay to share your feelings with them. The third thing is, if you’re feeling distressed, it’s okay to reach out for help. And when we look at people’s barriers, so physicians barriers to reaching out for help. The first thing is that they don’t have time. So we have time now, the second thing is that they don’t think it’s important enough or it’s bad enough. So it comes back to that idea of calibrating our distress. You don’t have to wait till you’re in crisis. The third thing is that they’re embarrassed. I think we’ve reached the stage where we realize that seeking support before you crash and burn is important. In the United States, every day a physician commits suicide. Every day in the United States, a physician dies by suicide. And so a lot of us may have noticed that our psychological well being is worse. We may have a diagnosed mental illness and there’s a lot of stigma around that. We may have depression diagnose, we may have anxiety disorder, we may have obsessive compulsive, we may have other things going on that are de-compensating because of COVID. So if you have a diagnosis, go back to see your care provider. If you think you might have a mental illness that’s not diagnosed, get some help. In Alberta, we are so privileged. We have the Alberta Medical Association, physician and Family Support Program. It’s free, it’s confidential, someone’s on the line 24/7. So reach out sooner rather than later. I’ll also tell you that Well Doc Alberta has prepared some resources for physicians by physicians, so they’re physicians specific. And if you go to our website, there’s things on sleep disruption, anxiety, there’s stuff about some little mini mindfulness recordings by one of the neonatologist at the University of Alberta, Dr. Marc-Antoine Landry, they’re superb. I reviewed the bulletin. I use them almost every night. There’s some great resources there that may help you. And then take care of yourself, the basics. Make sure you try and get outside, get some exercise, some nature therapy and carve out some time for yourself.

Ameer Farooq  56:29

You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.