E83 Jillian Horton

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Jillian Horton  00:00

Think you write a major work because there’s just something in you, that tells you that you must do this or that finds this important or cathartic or useful. I think without that, there’s just no way to get it done because there are a lot of points just like residency, at which writing a book totally sucks. And it’s distinctly unglamorous and not fun.

Chad Ball  00:35

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq, and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social or political. Our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all key surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features, such as debate and companion formats. We hope you relish the podcast as much as we do.

Ameer Farooq  01:18

We had so much fun speaking this week with Dr. Jillian Horton. Dr. Horton is an internist at the University of Manitoba and is a writer and just released a new book, “We Are All Perfectly Fine”. Dr. Horton explores in the book, her process of dealing with burnout, and her relationship to medicine. It’s a beautiful meditation on becoming a physician, and what that can do to both us and our families. We spoke with her about the process of writing the book, as well as what we can do to make the culture of medicine better for everyone.

Chad Ball  02:11

Thank you for joining us on a very special episode of Cold Steel. We’re extremely excited to have Dr. Jillian Horton explore a number of things with us today. Welcome, Dr. Horton. We know how busy you are, and we appreciate your time so very much.

Jillian Horton  02:25

Oh, thank you so much. It’s absolutely my pleasure to be here with you.

Chad Ball  02:28

You know, I was curious just to start us off, if you’d be willing to let our listeners know where you grew up, and what your training pathway was like, and how you ended up where you are now.

Jillian Horton  02:39

Oh, my pleasure. So right now, I’m in Winnipeg. And my story also begins in Manitoba. So, I was born in Brandon, which is a couple hours outside of outside of Winnipeg, for those of you who have never had the pleasure of driving through it. And I spent my life there until I was 17. And then I went to Western University where I did an undergraduate and a master’s degree in the English language arts actually with a heavy dose of drama and general humanities. And I originally was really torn, probably like many physicians, between the idea of a career in something to do with the arts or humanities and a career in the sciences. And I had done a lot of Sciences when I was a high school student, again, probably like many of you, I did the National Science Fair Circuit and that type of thing. But really, what drew me to medicine over those other things was the fact that from a young age, growing up in Brandon, I had had two siblings who were very profoundly disabled due to just random life tragedies. And that had led to a lot of contact for me with the medical community and a lot of learning good and bad as a result. And when it came time for me to decide what to do with my life to pursue this passion for the arts, and this drive to write, versus this idea of becoming a physician to work to change the system and make other families experiences better. I just felt I had to use what I had learned and seen growing up. So I went to McMaster Medical School. And then I did my residency and fellowship in general internal medicine at the University of Toronto. But Manitoba had a fishhook in me, and many people I know who live in Winnipeg who didn’t train here, they went away and then they came back. You know, our families do tend to take a permanent residence here. So I came back about 16 years ago, to be near my family and support them. And both of my siblings unfortunately have since passed away, but I continue to work at this kind of interesting intersection between the sciences and the arts. I guess that’s my fate, and have found a pretty good way to make things work here both as a physician and also, more recently, as a writer.

Ameer Farooq  05:12

You write so beautifully in the book about kind of this tension that you had. Being a writer, wanting to be a writer. You phrase it beautifully saying something like going and having Sherry with the tutors in Oxford, and in those hallowed halls. Because I think you were offered the opportunity to go over to Oxford and do that. And then ultimately, you talk about medicine as almost like this calling, not not so much even like a job. But maybe like as a vocation in the truest sense of the word, and as a calling. What was it that kind of, later on motivated you to come back and write this book, sort of years now into your practice, as a physician?

Jillian Horton  05:57

You know, I think most people who end up writing do it because of some internal drive to write. I think, if you don’t have that drive, you never get the job done. And the main reason I see that is writing a book, I think of it as an act of faith. But I also think of it as an act of total masochism. I mean, writing a book, the long haul, is really, really, really hard. And I know everything that we do in medicine, you know, our training is hard. The milestones are hard. And it’s just hard in a different kind of way. Because at least when we are engaged in these long residencies and training processes, we know that at the end of it, there’s a specific payoff. If you can finish your residency, you know that you will be a colorectal surgeon. Or you’ll be a general internist or a family practitioner. So there’s a finite promise of a goal as long as you can get the job done. But what’s interesting with writing a book is there’s no such promise. And the majority of people who want to write a book, and have a aspiration of having their book reach mainstream publication, anyone who’s trying to do that, or tried to do that will know what an incredibly challenging goal it is, and how distant the likelihood of commercial success or even just that book, seeing the light of day really is. So for me, I toiled for years writing and writing and writing. I mean, this particular book I wrote relatively quickly. But I often joke that really before this book, I had about a seven- or eight-year apprenticeship and failure, you know, trying to write a book that it came very close. One particular work that I almost sold to McClelland and Stewart. And there’s kind of an interesting, related point about that, too, which we could come back to later. But it’s really the idea that I think you write because you have to. And I think you write a major work, because there’s just something in you that tells you that you must do this or that finds this important or cathartic or useful. I think without that, there’s just no way to get it done. Because there are a lot of points just like residency, at which writing a book totally sucks. And it’s distinctly unglamorous and not fun.

Chad Ball  08:20

that’s a That’s a beautiful description. You know, like you said, sort of reaching or getting to a mainstream audience outside of the medical world is a particularly interesting challenge. And I think for those of us, you know that write a lot of textbooks, a lot of textbook chapters, a lot of peer reviewed publications, that’s an entirely different world. Maybe one of the things that I would assume crosses over, and I’d love your thoughts on the explanation is that I always teach the residents, you know the titles of these works are so critical. Like a really great title on a peer reviewed publication goes a very long way to getting noticed. I love the title of your book. I love it. We Are All Perfectly Fine. I’m curious what exactly you mean, for those who haven’t read it? And where did you come up with that? It’s superb.

Jillian Horton  09:12

Oh, thanks Chad. And, you know, I totally agree with you with what you said about the title and the hook. And another interesting tidbit I’ve learned over the last several years actually, more just writing op-eds, is the idea of answering this question before you begin, am I writing about a topic? Or am I telling a story? That’s often one of the most illuminating questions we can begin to answer when we try to figure out what we’re communicating, how we want it to resonate and what we hope it will achieve. But back to your great question about the title. So to me, this title sort of works on three different levels. And there are three different experiences for me that are really embodied within it. And one is we all know that in medicine, when we ask each other how we’re doing and how we appraise how we’re doing, we tend to say we’re fine, regardless of how we are. And there’s some interesting literature particular as a surgeon, particularly from the surgical field, looking at how studies out of the Mayo Clinic that you’ve probably seen done by Tait Shanafelt felt looking at how surgeons appraise their wellness, and they all over appraise it relative to their peers. So most people think they are more fine than they really are compared to when they begin to look at that, and rate their wellness and well-being on a scale. So that’s kind of one interesting idea: that in medicine, we lose the ability, I think, to have a sense of how we’re doing. To articulate how we’re doing. To accurately appraise that. And some of that, I think, is because in medicine, we just sort of disembody, right? We have to separate from our bodies, as I talk about in the book: to work through our physiologic needs, our hypothalamic drives for sleep and food and rest, you know? We learn to just say we’re fine as a default setting. And then there’s this other angle to me of, you know, what do physicians most want for us to say…patients, rather…when we as physicians walk into a room. They want us to say that everything is fine. Everything is going to be fine. And there’s sort of a craving for that consolation, that comfort. That reassurance from us is one of the main influences, I guess that affects a lot of our dynamics. People wanting the assurances from us. And then there’s this third piece to me. And it’s the idea of… Jon Kabat-Zinn sometimes talks about this idea of, you know, if you look at the surface of the water, and the water is choppy sometimes. And sometimes the water is very still. It’s all dependent on the weather. And he talks about this idea of going where the water is deeper. Dropping down further beneath the surface. And to me, it’s that third idea: that there is a way that often we need help learning to access. That it’s a state of a more …not eternal calm, that sounds like death. But a state of something that we don’t learn a lot in medicine, about how to access it, you know? Through some of these focused attention practices, through some of these medication practices that actually of course have the physiologic effect of toning our vagal nerve. Increasing our vagal tones. So tapping into beginning to have ways of getting to know that feeling that we are okay, that we can find an anchor from moment to moment during some of our most difficult experiences. There’s that level of fineness, too. And you know, the title. Actually, originally, when I wrote this book, I had the idea that it would be called the room at cheapen mill. But as I really went back over the manuscript and found that maybe that title didn’t mean as much to other people as it meant to me, the thing that kept emerging was this idea of how we’re fine. What that means, the superficiality of that word. And yet also the reality of it. That even in the midst of the crisis that we are living through now, and the really difficult clinical days on all the emotional distress and everything else, we can still find moments in which we do feel perfectly fine and allow that sentiment to give us some strength when we’re in more difficult times.

Ameer Farooq  13:42

Well, that’s such a beautiful quote from Jon Kabat-Zinn and this idea of going so deep. And I think one of the courageous things that you did in this book and putting yourself out there is you really go quite deep into your own struggles, your own triumphs, your own sadness, your own disappointments. And you talk a lot about you know, your own personal struggles with anorexia for example, and what it was like with your sister and her disability. And it just struck me as such a challenging thing for physicians to do. Because in one sense, you know, we wear these white coats, and they’re almost like, kind of suits of armor. And I think Caroline Moulton has this talk about surgeons in shining armor. And, I think it’s this very similar kind of idea that we want to project confidence to our patients and we want to appear perfectly fine, to use your phrase. So  what was that like? Kind of opening yourself up like that in such a vulnerable way? And how did how did that feel when actually putting that out into the world?

Jillian Horton  14:52

Yeah. What a great question. And so, to me, you know, the answer is that it is both easier and harder than it seems. And the answer is also that it is a process. It doesn’t happen all at once. We test the waters a little bit at a time. And so, you know, for me, I guess a number of things happened over time. And remember I mentioned earlier this book that I had been working on. For years prior to writing this book. It was a work of fiction about medicine. And I’ve shared a few times recently, the story of how, in almost selling that book, I was lucky enough to get it in front of the late, great Canadian editor, Ellen Seligman. And there was significant interest in this book, from McClelland and Stewart. But there were problems. They identified that there were a few structural issues and a few tonal problems that I needed to figure out a way to address before they would think about offering to purchase that book. And one of the things in a long conversation with this editor about the book. One of the things that Ellen Seligman said, and she really gave me a gift when she said this. She said, you know, I just find myself wondering a little bit: is this book really fiction? And she said this to me, probably six to seven years ago now in one of our conversations about the book. And that, even though at the time, I couldn’t recognize how important that observation was, it stayed with me. You know when you hear something at a point in your life, and you say, hmm. It resonates, but maybe you’re not quite ready to accept it. And I wasn’t ready to go there yet. And that’s what was wrong with that first book. That’s why, you know, again, I didn’t see it at the time. But the authenticity was not there. Because I was telling a real story. I was telling all these things that had happened to me and just dressing them up as fiction. But then you have to say to yourself, for a reader. One of the things I think we appreciate when we read certain kinds of personal narratives is the risk that is inherent in authenticity. We respect that if it’s, well boundaries, and we don’t sense that someone is trying to manipulate us or make us feel sorry for them, you know, those things are turn offs. But we believe, we know authenticity when we see it, even if we can’t always say why. And that’s one of the things that she really taught me in that comment was that the problem with the writing… and again, you know, fiction writers are not necessarily encumbered by this. It’s just that that’s what I was doing with this book. I was telling my own story, but not really being brave enough to own it, you know? Because at the end of the day, somebody could read it, and say, well, you know, she probably embellished this because it’s a work of fiction. She’s not saying it happened to her. And I slowly realized that in order to write a book that would really resonate as authentic for me, writing about medicine. Maybe it won’t be that way, someday writing about something else. Maybe I’ll be able to write fiction about, you know, family life or whatever. But writing about medicine, it just was falling flat for that reason. And so I slowly came to the realization that if I wanted to write the book that I knew I was technically emotionally capable of, I was going to have to own that experience. And I was going to have to go places that were going to be uncomfortable. But it is one nice thing about having the time of year to write a book, because it’s a long process. You have a lot of time to get used to the idea. And you can, you know, seek the input of your trusted friends and mentors. And then the people who don’t know you, right? Agents, publishers. I mean, they will respond quite viscerally to what is too much, what is not enough, what feels inauthentic. And I guess the other interesting thing: a lot of people since the book came out, they say to me, wow, like this must be so overwhelming for you to have this out into the world and all this personal stuff. And by now I’m totally desensitized to it right? Because this book has been in someone else’s hands for two years, this October, right? Since the first time my publisher saw it. So I had a long time to get used to the idea, and accept this idea and feel comfortable that I was putting all this out into the world. But I guess, because I think this is such an important question. And there really has been just lately a lot of interest in the research question of the power and utility of personal narratives for cultural change in medicine. You know, I think some of the things I really had to work with, I often identify them as kind of categorically five different things. One is the fear of disclosing personal health information and the liability and the professional failure that goes along with that. Obviously, we all see personal health information as sacred. So working through that is inherently challenging, but it can be done. And you know, having read my book, you know that sometimes I tracked down real families and got their permission to share actual stories. Other times I couldn’t do that. So I simply had to create stories based on my experience in order to protect the sanctity that everything in the book has an origin in my, as I’ve alluded to in the author’s note. And then I guess the other things, you know, we fear social pain, we fear our colleagues saying, oh, god, what is Chad writing about in this? This is so personal. Yep. We don’t want to know this. And we fear people, sometimes the gender narrative. People saying, oh this is, you know, a woman writing about this. And she should have just chosen a different career if she can’t handle what this profession demands. Or the other thing was, you know, I write quite candidly about some things that happened to me as a medical educator that weren’t good. And even that was a calculus for me, you know? I’m a lifelong medical educator. It’s so important to me in terms of identity and values. But even there, I had to weigh, am I okay saying…just like that editor who said to me, is this really fiction? Am I okay saying, “I’m not going to talk about that, because it’s going to stress people out. And it might promote some backlash, and it’s going to make people uncomfortable.” If we want to change this culture, we have to be willing to talk about every single part of it. We can’t say sorry, that’s off limits, sorry, we accept the idea that hierarchies only work one way, that there’s never harassment that occurs in other directions. That the learning environment is not part of an ecosystem, you know? So even all those kinds of things, just a slow process of saying, yes, there’s risk inherent in writing about these things. And all of these aspects I’ve just listed can cause us distress when we write honestly. But what I decided at the end of the day, is there’s a much bigger risk to not telling a story like this. I know that I’m technically capable of writing a book that really depicts some of the realities of medicine. And therefore, there comes a point when you say, maybe, therefore, I actually have a responsibility to do that. Maybe my ability to communicate in a way that hopefully feels realistic and authentic and universal to my peers. Maybe by not doing that, I’m taking a much bigger risk, and failing to do what I set out to do originally, which was have some positive impact on a lot of core aspects of our culture. So it’s scary, it’s threatening. I guess the last thing I’ll say, very long answer, is through the process of, you know, just this happened by fluke, right? Because when COVID hit, like all of us, I was beside myself. You’re sort of going a bit ballistic, as you watch people make the wrong decisions from the public health perspective and poor communication. And I felt I had to do something. So I just started writing op-eds. And interestingly, those op-eds became progressively more personal. Put me, like any of us who have spoken about COVID, they do subject us to more harassment and kind of trolling and that type of stuff. But you know, that was also a great way to flex that courage muscle around personal narrative. Each time to think, oh, I’m going to get backlash about this. And yes, some jerks would harass you and troll you. But much more commonly, the response was, thank you. Thank you for being brave enough to say that. Or, oh my God, I had no idea that other people felt this way. You articulated something I’ve been trying to say for 10 years or carrying with me privately. And that is what keeps, you know, those kinds of messages, that kind of feedback. It’s just like people cheering you on. And each time it makes you a little bit more able to tolerate more risk.

Ameer Farooq  23:41

Yeah, I’ve seen on Twitter, just the outpouring of support and acknowledgement and just shared the kind of thanks and gratitude for reading your book. And I think it just resonated with so many people. Because you were able to stay so honest and true to what your experience was, and what the challenges are in our current training environments and what the career of medicine sometimes does to us and what it forces us to do. And I want to circle back to you know, the piece that you talked about taking that calculated risk as a Associate Dean. Because I actually thought that was one of the things that really resonated with me so powerfully. Dr. Ball and I’ve talked about this so much. You know, on the podcast and offline. You have this great quote where you say, “Medicine shouldn’t infringe on their wellness at any time or in any way”, as if the Associate Dean’s job was not to make health medical education safer and more humane, but to make it more convenient for them personally. Not so much level the playing field as “raise the mountain”. Can you talk about that? Because to me, I think that discussion and not acknowledgement of kind of the neediness sometimes of us as trainees, it kind of gets muddied with this idea of taking care of people in medicine. Like, can you unpack that for us a bit?

Jillian Horton  25:14

That’s such a great question. And you know, you’re absolutely right. This is a particularly tough conversation right now. Because especially as an educator, it’s very easy to have this message quickly misconstrued. And I think it’s why you almost can’t really see these things until you have a clear cut track record, as an educator, of being compassionate. Of being student-centric. Of really advocating for students in a meaningful way. And one of the funniest things Ameer is you know, after reading that chapter, so many students have sent me messages saying, you know, I just feel like I asked too much of you. And I just sort of laughed my head off, because I think you’re not the people I’m talking about. You are exactly the people that I was there for in the first place, the people with, you know, sick parents, the people with health issues, that people with personal issues that were really challenging and difficult. The people who had painful cases that traumatized them during med school. I wanted to be there 100% in their corner. But as with many things, you know, is one of the shifts that worries me in medical education. Some of this I pin on accreditation. So we’ve had an accreditation culture that has shifted, and it’s critical that we have an accreditation process, right? We desperately need standardization. But I’m not sure that we use the right language in accreditation, you know? Is being satisfied or very satisfied the ideal metric for judging the quality of our education? I mean, I’m not satisfied with some of the things that have happened in my residency around my medical education. But I can definitely tell you that some of those things made me a better physician. But again, that’s where the conversation becomes explosive. Because people say, well, what are you talking about? Are you saying it’s fine to be up for 30 hours? No, I think for the most part, knowing that there is lots of nuance and lots of variation between specialties. I do think generally, our work hours are too long. They exceed what we are actually physiologically capable of. And we know, again, when we look at the data, work hours longer than 60 weeks are one of the things that are associated with higher burnout in all professions. But, you know, it’s really this idea that framing the learning environment as a place that it’s our job to make safe, as opposed to framing it that we have to make our entire culture safe, and better and higher quality. And that is a responsibility that goes both ways, you know? So I feel that just the shift, even in the idea of entitlement in medical education and in medicine in general. Entitlement in medicine as a behavior that we see, you know, in my peers. In people who are practicing physicians. Like it doesn’t just start one day, the minute you end residency, right? Sometimes it’s a ripple that permeates our entire culture. Sometimes it is baked into our culture, it’s something that people come with, because medicine is still, in many cases, something that is more likely to be an opportunity for people who come from backgrounds of privilege. And so all these things, you know, really have to be discussed very openly. But the problem so often is that in trying to discuss them with subtlety, recognizing that they’re difficult conversations, that more than one thing can be true at once. That the learning environment can involve a lot of harassment and abuse for trainees. And yet everything is not harassment and abuse. That is a tough conversation. And the political climate right now can sometimes make that more difficult. And certainly, I’m sure you’ve also had colleagues who have said, you know, I’m afraid I looked at someone in a way that they didn’t like, you know, I was squinting at them because I didn’t have my glasses on. And they said, I was glaring at them. And now they’re saying that, you know, this is abuse, this is harassment. And so you know, like these are real kinds of examples of things that are happening in our learning environment right now. And it’s just kind of cheapening, muddying, destroying the whole purpose of what we’re trying to do. So it’s complex. And we have to be willing to tackle it as a complex problem. As interpersonal things, as very complex. As, you know, the whole range of behavior variable situations, as opposed to just saying, you know, I don’t think we help anybody when we take an approach that’s just like, you know, if you say that I was rude to you, then there’s no other possible explanation for things. Because guess what, five years after you finish your residency, you’re going to be an attending. And if we haven’t created more nuanced sophistication, and fairness, and just, you know, emotional intelligence in that whole process, you’re just going from one environment that was overly protected to now an environment where you have no protection. And suddenly you are on the other side, and there shouldn’t be sides, you know? This should really be looking at the lifecycle of our profession. How do we make everything better? Not just one short phase of it, because that doesn’t help you, when that phase is over for you. So lots of thoughts about that. I’m curious to hear what you think of some of that, too.

Chad Ball  30:51

You know, you’ve unpacked so many things there in such a beautiful way. There’s so many different directions we could reflect on, but I want to particularly focus on, you know, your concept of the reality that…and I hate to use the word bullying in this scenario. But that friction can go both ways. And you can be in scenarios as the educator or as the physician, or as whatever sort of a descriptor you want, where it does come from maybe non-traditionally recognized sources. And whether that’s, you know, a nursing complaint in an emergency department against a service or a physician, whether that’s a trainee towards an educator. And you’ve given a beautiful example of that with an incorrect or a challenging glance. Two parts: how do we deal with that reality? Because I think that for many physicians who find themselves unwittingly or unpredictably at the sort of end result of those processes, as you point out there, they’re now very politically entrenched and tend to be guilty before discussion. How do they address that? How should they frame that? And then I’m curious, you know, these concepts that you’ve provided us, you know, the last few minutes are so.. like, I mean, I’m biased. I love them. They’re beautiful to me, they make sense. But how do we actually mechanize that, to a practical extent in our training systems, as residency currently is sort of constructed and how our interaction with trainees in general goes?

Jillian Horton  32:42

Yeah, what a number of great questions. And, you know, just, again, to go back to the first point that you made about the non traditional constructs and examples of harassment, or bullying or whatever that can occur. You know, if we look at our current construct, and accreditation, that the focus is on making the learning environment safe, I always remember 20 years ago, when I was a resident, I was working with another resident who actually made a comment after a negative evaluation to our preceptor, about, you know, he was so angry, he felt like killing her. And there was no response to that event. And if you think about just that example, you know, or the response was extremely muted, in that case, to put it mildly. But if you think about it, our current constructs don’t allow for that example. That that sort of bottom up type of, we don’t necessarily call that or frame that as harassment or abuse. And so it’s a) recognizing that our models are quite crude. That they’re based solely on constructs of power. And not all the variables, including gender, including being a member of a bipap community, including all these other things, as you mentioned. But you know, one thing that I think often helps: the more relational an environment is, the less likely we are to resort to complaint processes, when there is a one out of 10, two out of ten, three out of ten misunderstanding. If we have a more relational environment. And you know, an environment where we are encouraged to talk to each other, to know a little bit about each other, those conflicts will not tend to ignite in the same way that they do when we know nothing about each other. So you’re meeting another physician for the first time, you know nothing about them, you don’t realize that your kids go to the same school, that you both went to the same medical school, there’s nothing to connect you. This is one of the ways I think that just bad behavior, rude behavior, anti-social behavior takes off. So that’s one part. But the second thing is: we have a pattern in medicine, as we all know, of only intervening when things are at a crisis. And if we look at some of the management models for difficult behavior in physicians, for example. Hickson’s model, the cup of coffee, you know, intervening very early, when if we’re colleagues and you hear someone reputable or whose perspective you, you know, has inherent validity, but or even if you don’t know them, if you just hear that, you know, one day I was rude to someone, or snappy, etc. Sharing that feedback with me – not as a complaint, not putting me in front of a jury, not stripping me of my role – but saying, you know what, I heard this about you. And I’m just telling you about it. I know there are two sides to every story. And if I hear it again, we’ll have to have a different kind of conversation. And what’s interesting is, you probably know in a lot of the literature around disruptive physician behavior, is that initial intervention is extremely effective. So most people, when there’s a conversation like that, they will never have a second conversation with their superior about behavior that will truncate a lot of it. We also know that somewhere between two to 4% of physicians just have difficulty being respectful towards anyone. And so that’s one of the other problems we face, right, those two to 4%. And this is something I wrote about fairly recently in the Globe and Mail, this idea that these people, well, they’re so valuable, that they can just continue to do whatever they do. And the system accommodates them. The system modifies its behavior, people walk on eggshells around them, etc. And it you know, it’s sort of occurs to me as well, that these problems for the most part, when we look at them and institutions, everyone names the same people as being difficult in, in a lot of cases, you know, we all know if, if you were to survey, who are the three most interpersonally challenging people to work with in your group of 40 people, the lists are going to look very similar, right, you’re going to have a lot of repetition. But what’s you know, interesting is when you look at how many times like, who has who’s dealt with those people, what had the intervention spin? The answer is often nothing, they’ve never received any feedback, they never been on any kind of behavior management problem, even though these are chronic issues, not those singular kind of things that we talk about, that are dealt with in the tribunal fashion these days. And, you know, something that occurred to me recently, in terms of this problem with the, the way the pendulum has swung so far, in terms of how we’re dealing with signal in the learning environment, it’s to me, when you think about it, most of the people who are now making the decisions about what we do policies in the learning environment, how we’re going to deal with problematic behavior, they’re actually the same people who have not been able for the last 30 plus years to deal with disruptive behavior in their own ranks. So now they’re applying the same failed metrics that, you know, they’re doing the same things that they were unable to do using those same techniques, now to try to address the learning environment. And when you look at it, that way, it becomes more clear why those efforts are not being successful, because actually, those people are being tasked now with just doing another version of something that they really haven’t been able to do before either. And it tells us that we need an entirely new approach and way of looking at these things instead of just this, you know, kind of hitting everything over the head with a hammer.

Chad Ball  38:21

I agree so much with everything you said. And you know, your start there about being mindful and putting effort into building relationships in our environments, is so critical. I think it’s probably, you know, intuitive and sounds common sensical to most people who will listen to this. But the reality is, it’s not an excuse, I think it is just a reality. And they can’t be overcome that, you know? Our inpatient in-hospital environments are challenging environments to do that in. If you happen to work, for example, at a quaternary care facility with 1000 beds and all the illness and the pressures that come with that, sometimes it is hard to create those and nurture those relationships. Again, certainly not impossible, but you’re right, it does take effort. It does take thought, conscious thought to really achieve that. And I couldn’t agree more, whether it’s between individuals at its core or between groups, you know? Or services. It’s essential, eh? And there’s so many different ways to achieve that. But boy oh boy, it’s important. And you’ll see that for those of us I think, that travel around in various capacities a lot, right? You walk into hospital x in Los Angeles, and you just get the immediate sense of the camaraderie and the productivity and you say, “wow, am I jealous this environment” for example, you know?

Jillian Horton  39:51

You reminded me of something Chad. I always thought this moment was so masterful. A surgical colleague, who I actually had just met for the first time – he had come back to Winnipeg after working somewhere else. And one day overnight, one of my internal medicine residents had had conflict with one of the surgical residents. And my resident called me and said, You know, this person was doing this. And this was so unpleasant, and they were so inappropriate. And so I challenged them. And they said this, and they were, you know, really just relaying, if I could have summarized what they were telling me, and what that other resident was probably telling their attending, it was just like, I’m right, they’re wrong, you know? So we were sitting doing our case review, post call, and the surgical team came into the word. And I, again, I’d never met the surgeon before. But he came in, and you could see the tension right away between these two residents. They were ready. And they started sort of sparring passive aggressively. And the attending surgeon stopped for a minute. He said, you know what you guys need? He said, you need to go have a cup of coffee together. And I was just so relieved to hear somebody else say that, you know? It was also a really masterful moment, right? It was deescalating. And illustrating to them like, this is not about turf, or our tribes or just vanquishing the other party. This is relational. You know? When you think of this to me…if you look at some of the programs that have been really effective at mitigating burnout, the Mayo Clinic’s model of having people have meals together, that kind of thing, that fancy French word of common salad, simply breaking bread together. I mean, these are the things that make us like each other. And when we like each other, and feel a little bit of empathy for one another and know just a little bit about the ways in which we are alike, it is much harder than to mistreat each other. To say nasty things about each other. It’s sort of trying to find things to like and connect with about each other. And you know, as we all know, this actually is not typically cultivated in teaching hospitals and our departments become more and more insular, more and more prone to slagging each other. And at the end of the day, that hurts patients because it means we cannot collaborate as well as we need to. Our relationships, and our psychological safety dealing with each other absolutely influence patient care. And the second thing is, it influences our quality of life. You know, we all remember the physician at the University of Rochester… I’m blanking on his name, but he spoke at the ICPH a couple of years ago in Toronto. And the comment that he made that just stayed with me is that we all want a more relational environment, whether we know it or not. And I think about that constantly, you know? That even my colleagues who sometimes really struggle to find anything, you know, to celebrate in our interactions, or to find anything to feel empathy towards, I think to myself, this person has been conditioned to behave this way. In a different environment, for the most part, they probably would not be so difficult to work with. And you know, the last part, of course, for the humility piece of it is for all of us to accept that when we have interpersonal conflict, for the most part, usually, we have also done something to make that conflict worse, because our motivations and our insights into our own motivations are often really limited. Which to me, is where that mindfulness piece and that self awareness aspect of things becomes really helpful. We can begin to see our own patterns with a little bit more clarity.

Chad Ball  42:40

I think that’s so beautifully said. You know, I think if we were to stereotype maybe unfairly…but I think probably honestly, about physicians in general, myself included, we certainly do have big blind spots when it comes to self. And insight, and a number of the descriptors that you use on occasion. And I think that, that’s truer, or less true over the extent of a career and we have to be mindful of it for sure. One of the terms you used in that piece was burnout. You know, we’ve been lucky enough to have Jane Lemaire talk to us about burnout here. And I’m sure you know, Jane well, but I was curious, in particular, how you define burnout. And then obviously, as a vessel, as a voyage, you know, most publicly with regard to your book. How it impacted you personally. Because we really did sort of in that preceding podcast with Jane dance around the academics and the mechanics of it without really talking about it at a personal level.

Jillian Horton  44:41

Yeah. Well, the personal level, I think, is almost the most meaningful one to answer the question. Because I think when we think of the usual trifecta of what we think of Maslock’s defintion of burnout, you know, we think of it in a very rigid way. We have a preconceived notion of what that actually looks like. The decreased feelings of personal accomplishment, the depersonalization, the sense that the work doesn’t matter or feel pleasurable, etc. But you know, I sometimes like the idea… there’s a quote in her work elsewhere about the dislocation between our values, and what we’re doing. I think that’s a very powerful framing. But what did it feel like for me? You know, I don’t think I ever recognized myself, at many previous points in my career as burnt out. Because for one thing, my interactions with patients never changed. You know, I’m always, I always feel like I’m quite present with patients. That I’m quite engaged. That I don’t feel ever depersonalized from them. And you know, because of that, I don’t think I ever fully recognized myself as having the syndrome of burnout. But here was the manifestation for me: it was coming home at work, and having absolutely…from work rather. And having absolutely nothing left. Not one other thing to put on the table. My kids, and my spouse, and my friends and my extended family, getting the absolute leftover scraps of me and my attention. So for me, it looked like paying full attention to my patients, being totally present with them. And having nothing left for the rest of my life. That other part of my life was so atrophied. And, you know, the emotional depth of it was so limited. That for me, is where I really have experienced depersonalization over the years. And this fits with our knowledge of you know, how physicians behave and experience burnout, right? Our patient care is the last thing to go. So when we have colleagues who are doing a poor job with patient care, snapping at patients, being disrespectful, that kind of thing, and that’s not characteristic for them. We know that’s a very late stage finding. So sometimes I think our framing, you know, the way that we think of it, the feelings of what emotional exhaustion feels like, it doesn’t have to be localized to work. You know, for a lot of us probably my guess is that it just manifests in every other part of our life. That there’s nothing aside from work that we feel engaged with or connected to. And that’s the way that for me, looking back, I really see that pattern cycling throughout the last decade of my life before I became more aware of the things that I needed to do to deal with and address that for sure. And I think sometimes when I’ve shared that with people, I’ve certainly had a handful of emails where I’ve been talking about that and after the book coming out, where very senior people have written me and said, I never thought of it that way. And actually, that is me, and I never considered that to be burnout. But I guess it is. So to me, that’s one of the things that when we’re looking at the academic definition, we have to be ready to look and apply that to the rest of our lives to see how those patterns may be manifesting in ways that actually are really painful for us to see in totality.

Ameer Farooq  48:14

That’s interesting. I think people always talk about, you know, having balance in their lives. And, you know, make sure you have a hobby, or I don’t know, go for a run every morning. And that’s going to prevent you from, or protect you from burnout. But you know, it’s not actually necessarily that you don’t have the hobbies, it’s that you’re already at this point where you can’t appreciate or enjoy the things that that you like doing any more. And I think you’re so right by saying that. Let me ask you one final question, which is, you know, you have two children. And you talk so much about what a challenge sometimes medicine puts on us and a burden, perhaps it puts on all of us, would you recommend or encourage? Or maybe the better way of saying is, would you discourage your children from going into medicine, having kind of experienced all that you’ve experienced?

Jillian Horton  49:03

People have asked me that before, and probably both of you know, some of that literature around, “do physicians recommend generally that their kids go into medicine”. And in lots of the US studies in particular, there’s data that the predominance of physicians say they would not recommend a career in medicine to their kids. My answer is a bit more subtle. And I think I would really want to know their why. What their motivation was. That they were going in with eyes wide open. And what meaning and purpose they thought they would derive from the work because as we know, in the literature, a strong sense of what our meaning and purpose is, and what our connection is to that meaning and purpose through the work that we do is one of the things that gives us immunity from burnout. And one of the things that continues to make our work feel more like a calling than a job. So for me, really exploring that with them and making sure that they knew that, I would not discourage one of my kids from going into medicine. But boy, I would want to make sure that they had as much of an understanding as possible of what they were doing. And frankly, I’d probably want to make sure they read my book.

Ameer Farooq  50:23

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.