Unprecedented: COVID-19 and its impact on physician wellness

“I can honestly say I have never been through anything like this in my life.” – Dr. Sabrina Akhtar, Toronto.

When a global pandemic was declared in March 2020, medical professionals went into hyperdrive to try and contain the virus, treat patients, and keep themselves safe. Nearly a year later this work continues, but what is the cost to physician wellness? Do we need to re-think wellness supports during COVID-19?

In this episode, Dr. Sabrina Akhtar explains the stress and burnout she’s experienced since the pandemic was declared, and Dr. Caroline Gérin-Lajoie talks to Dr. Joy Albuquerque, medical director of the Ontario Medical Association’s Physician Health program, about how she sees the pandemic impacting physicians.

Want to learn more about physician wellness? Visit the CMA Physician Wellness Hub for curated, clinically-based tools, resources, and research on all the topics covered in this podcast.

Transcript

Episode One

Unprecedented: Covid 19 and its impact on physician wellness

Caroline Gérin‐Lajoie (intro):

Welcome to "Sound Mind," a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gérin‐Lajoie Gérin‐Lajoie. COVID‐19 has affected everyone in a multitude of ways. For healthcare providers, the challenges have been at times overwhelming. In many parts of the country, case numbers reached record levels in January.

Uncertainty is growing about the healthcare system and the capacity to care for everyone. It's hard to overstate the stress that this places on our physicians. Dr. Sabrina Akhtar is a family physician who's been working at a COVID assessment center in Toronto and is the director of a home‐based care program at the Toronto Western Family Health Team.

Here's how she explained the impact of the pandemic on her wellbeing, starting when the pandemic was first declared in March.

Sabrina Akhtar:

I can honestly say I have never been through anything like that in my life. I can't comment on whether that's a positive or a negative. I'll just say that it stands alone in my memory as something that I faced, my team faced, my colleagues faced, and my partner and I faced, our family faced together. There really hasn't been anything like it since, and I hope there never will be.

My colleagues and I barely had time to talk about this. It was happening like a tsunami. We connected online. We were texting and chatting, but it's not something we debriefed in the moment. I can't say that it was.

The adaptation at home had to be just as quick in the same way that things shut down at work and went online and the COVID center popped up within a matter of days and my whole day [laughs] changed unrecognizably, so did home life.

My partner and I are both in medicine. We very quickly realized there was no way we would be able to focus and contribute in a meaningful way if we were worrying about the family. We split up for a bit of time. We sent our kids to a set of grandparents. They stayed there for the better part of a month.

At the time, there was just so very much to consider day to day. Our hours extended to a point where ‐‐ I don't mean it figuratively at all ‐‐ we literally worked on COVID initiatives and direct patient care from the time we woke up until the time we went to sleep. Once we saw that we could no longer sustain that, we brought the kids back with some in‐home childcare measures in place.

The anxiety has subsided, I think, although I suppose I don't know because I haven't taken much pause to ask myself or to understand. Sometimes, it's only looking back that you realize how difficult a particular time was.

The sheer fear of waking up [laughs] every morning and feeling that feeling in the pit of your stomach, not being able to sleep at night, watching much, much more TV late into the night at the end of the night than I ever have in my life just to try to shut off the jitteriness, the edginess...that has settled.

That has settled as we've become confident in things like our protective equipment and our protective equipment supply chain. I think that was an underbelly of anxiety for many of us in medicine for many weeks until we were sure that we were going to be safe.

Since then, it's a different kind of anxiety. There's a fatigue that has crept in. In some ways, it's a better feeling, and in other ways, [laughs] it's a different evil. We no longer worry about going into work, but we know what to expect. It's exhausting, and there's an exhaustion that comes with riding a rollercoaster.

This is a good day. This is a bad day. This is a tough week. I picture it as a moving target. COVID has been a constant moving target that we are constantly chasing.

There's no doubt there's going to be something that comes out of all of this and an impact that we simply won't understand until the dust settles. As physicians, we are trained, conditioned, socialized. I don't know what you call it, but we very naturally put aside our own needs for those of our patients.

I think of a busy clinic where I don't even take a sip of water, or I think of an overnight shift where I don't eat anything, or I don't go to the bathroom. [laughs] It's only at the end of that clinic or at the end of that shift that I realize, "I don't feel very well." It's not throughout. It never is.

The adrenaline, the satisfaction looking after others, a lot of things keep you going for those shifts and those clinics, but at the end, you realize that you are very hungry, or tired, or thirsty, or uncomfortable, and you don't feel very well. Imagine if that shift was 12 months long. Nobody knows.

I don't know when it actually pauses, and we can turn inward and say, "How am I feeling, because it's truly over," what we will feel. I can imagine from my experience and on a micro‐level going through stressful periods that there's going to be some damage that will need assessment.

Caroline Gérin‐Lajoie:

Dr. Sabrina Akhtar, a family physician in Toronto, talking about her experience during the pandemic. It was recorded in late November when COVID cases in the city were rising rapidly. Since that time, the situation in Toronto and other cities has only gotten worse.

Joining me now to discuss the impact of COVID‐19 on physician wellness is Dr. Joy Albuquerque. Dr. Albuquerque is the medical director of the Physician Health Program with the Ontario Medical Association. Thank you, Joy, for being with us.

Joy Albuquerque:

Thank you, Caroline. I really, really liked hearing what Dr. Akhtar said. She captured so eloquently what the experience was like as this pandemic descended on us. You know that everybody's galvanizing and feeling the urgency and rising to it with all that energy, even despite all that uncertainty, but the fatigue that people are feeling.

Today, even, with the headlines of the ICU beds and the worries about how to manage when we are dealing with so many people who are still getting the virus and becoming sick, and people being sick for other reasons. The pressure is still on. Wellness has never been more important as it is now.

Caroline Gérin‐Lajoie:

In terms of your role as the medical director of the Physician Health Program at the Ontario Medical Association, are these the types of issues that you and your colleagues have been hearing about from physicians? Reports of high anxiety and worry or reports of fatigue?

What kind of wellness issues have you been hearing about and tracking over these last few months of COVID?

Joy Albuquerque:

So much of it is that the worry of, "How am I going to keep going when we don't have an end in sight?" That's a challenge that every one of us faces as you wake up in the morning. What we're hearing from physicians in Ontario is that they're going to do the job, that they're on this.

Sometimes, they feel like they don't know how they're going to get the energy to do this and they don't know how they're going to manage, especially as we're finding colleagues getting ill and people having challenges with other issues in life that are also real.

There's the recognition and perhaps even a bit of a resignation in a sense that we don't have a choice. We have to continue in this way. Lot of the doctors are talking about this, and they're also talking about that there are some things that are a lot better in terms of where we are now. We have a lot more information now.

PPE, which was desperate and was such a concern at the beginning, is less of an issue now, so there's this confidence that the system has righted that. I think that some of the challenges are the expectations that continue to be there, that you need to continue to work exceptionally hard.

This is why, again, I think that the wellness discussion today is so important. Sometimes, that gets forgotten. In all of the reports, of all the important things that have to be said, and should be said, and need to be said, (it's important information), but our health and wellness and how we're doing, sometimes, it does, it gets missed.

Sometimes, people will be thanked for their service. To me, that's wonderful to hear and it is talking about a value, but it's very different than saying, "I know this is having an impact on you, and these are the resources that we have. We value you being well, but if you are not well, we want you to get care." That's the message we want to continue during this time and after.

Caroline Gérin‐Lajoie:

That goes back to the old saying that, "Human resources are our most important and valuable resource in the health system," isn't it? We need to support it as best as we can.

In general terms, what is your sense of the demand, in terms of requests for help or support to your program, to the Physician Health Program and also to other programs across the country as compared to last year, for example?

Joy Albuquerque:

It's interesting that especially places that provide services to all health professionals, clearly, the other professionals that are not doctors, are much better at seeking out care, which is an interesting thing for us to take note of. Why is it that doctors are not, because certainly, this is impacting us the same as everybody else? That's one point.

That being said, we've had at least double the calls, if not more, to our program. We also know that all the hospitals and a lot of the facilities and mental health agencies are also offering services. CMA has offered the Wellness Support Line. There have been government offers for everybody.

There's a lot of so‐called help out there and still, we are getting at least double the calls. That speaks volumes. These are people who are quite distressed. Some people being proactive, some people saying, "You know, I don't know if I'm burned out, but I think I might be and I kind of want to just do something about it now."

Or, somebody who comes and says, "You know, I lost it with my kids last night. I always have time for them. This is a sign for me, and talking with my partner, I'd love to get a little bit of help." It's that kind of thing that we're hearing. We're also hearing that people are drinking more. They're using substances more. Everyone, the broad population. That is the same for doctors as well.

As you know, Caroline, that's not necessarily a substance use disorder, but clearly, under these types of chronic stress models, the use of alcohol does not help. It does not reduce cortisol. It does not dampen your stress response. It doesn't, and that's quite clear in the literature. It's good for people to know it's not an antidote to this kind of stress.

It's not a problem to have a glass of wine or [laughs] have one drink, but to use it as a drug is obviously a problem. I think that we are seeing an increase in people who have found themselves problematically drinking and wanting some guidance, and some people for whom it has revealed an actual illness, whether it's a substance problem or another mental health condition.

Caroline Gérin‐Lajoie:

It sounds like an increase in demand for services or for help from the Physician Health Program may be a sign of both that there is increased distress overall, but also that some physicians are now starting to call out for help more proactively, more preventively, which is a tremendously positive sign and maybe a small indicator that our culture is starting to shift in our physician and learner community.

Earlier this month, we learned about a physician in Quebec who died by suicide, Dr. Karine Dion. According to media interviews with her husband, stress from the COVID‐19 pandemic led to her death. What are your thoughts around that tragic event but also the topic of suicide within our physician community?

Joy Albuquerque:

First off, I need to say how sorry I am to hear of this loss to her husband, and family, and friends, and colleagues, and people who cared about her. It's so sad. It's one of those tragedies that all of us feel. It does impact us all.

To hear that COVID or the impact of COVID was a huge part of it, that heightens this feeling inside me that we have got to get the message out more. If we can move things, can you picture what a day would be like where somebody comes to somebody and says that they are having some desperate or suicidal thoughts? If the response of the individual was to hear it, to listen, to go, "My goodness, this is an emergency and I need to act now, in the way that this is an emergency." One of our ATLS courses, we need an ATLS course for suicide so that we go into action and we get that person to help.

We know that there's so much we can do to help support and treat, if there's a condition to treat, and at the very least, hear this person's suffering and help them for the next step. I feel that this is something that our profession can do superbly. We could be the leaders in this.

It starts by acknowledging, first of all, that vulnerability exists in each and every one of us. We all have a limit. We all have dark thoughts. We all have tough days. Studies say without even a health condition impacting, probably 6, at least, maybe 10, maybe more percent of people will have had suicidal thoughts at some point in time or the idea that they need to escape in some way.

If it's that common, surely, we can accept it as something that is possible. I find that the challenge as to why we don't and that this happens in every area in medicine. There's something about knowing that somebody is suffering to that level that connects internally and you don't want them to be suffering, and you don't want to know that somebody could be suffering to that level. That is a bit of a barrier.

Caroline Gérin‐Lajoie:

I like that idea that with increased awareness, increased normalization, increased skills and information, I do believe the physician community is one that can do a great job at looking out for each other, at helping each other.

Where I think there is still a lot of discomfort and stigma is at the individual level. In the conversations I've had with physicians across Canada, many would feel very comfortable, and in fact honoured, to listen to a colleague's mental health issues.

When it came to themselves, it was the opposite. They would feel extremely uncomfortable going up to a colleague to talk about their own mental health suffering or concerns. There's still a dichotomy, in terms of what we think is appropriate for others but what is appropriate and safe for us.

In all of our work, national, provincial, local, we all need to somehow influence the individual's beliefs, and attitudes, and comfort level to be able to reach out for help more easily.

Joy Albuquerque:

That's so true. When we think about it and now we're hearing about COVID stigma that there are people who feel that if they get COVID, that they're going to be judged and that somehow they did something wrong. Even if they don't even know where they got the COVID, it's somehow their responsibility. They should know better.

I think that's the piece. That is almost like a distortion in the way we think as physicians. We're supposed to know better. That somehow leads to the belief that we're supposed to also know really well how to have the skills to manage with stress, a pandemic, an illness.

It just doesn't seem to matter. The list goes on. That's a part of it that we have to accept that we're incredibly good at managing things. We're very good at managing stress. We are excellent at creating plans and saving lives.

If we take the time to get to know ourselves, get to know our own stress temperature check if you will, and how we're doing, maybe a bit of kindness or friendliness toward ourselves, I would be intrigued at how that might shift some of this harshness that we have towards ourselves in the expectations.

Caroline Gérin‐Lajoie:

Dr. Akhtar talked about the long‐term impact that the pandemic may have on physician wellness in the longer run. I wonder, Joy, what your thoughts may be about the potential long‐term impacts on the medical profession in terms of wellness?

Joy Albuquerque:

We know that this pandemic will end. We know that it will end. We know that there's going to be post‐trauma growth, post‐pandemic growth. You and I know that 40 to ‐‐ who knows ‐‐ 70 percent, depending on what group you're looking at, of individuals prior to the pandemic were already burned out.

They were burned out because of a lot of things that were challenges in a system that has been changing so quickly, doing its best but needing change even before the pandemic. There's a lot of concerns about the idea that we will just go back to this, never mind have we been leaders in caring along with a lot of other people.

Not only are we exhausted by this, and challenged by this, and the grieving and the losses that people have had to experience through this work. On top of that, what are we going to face? Is it going to be the same? That's an important thing for leaders to be aware of.

It's an important thing for all of us to be aware of because going back to a place where we feel overwhelmed getting up in the morning is not going to be OK. I am concerned about that. I'm a little buoyed up, I guess, that the system was listening, that the system is aware.

There are a lot of people who are starting to think about some of the changes that need to happen in medicine. That's encouraging, but we have some work to do as this pandemic winds down.

Caroline Gérin‐Lajoie:

Related to that, with what you've said about your thoughts on the long‐term impact, are there any changes you think should be made to wellness supports? Do we need to rethink wellness supports for physicians, for learners, and even for their families?

Joy Albuquerque:

Yeah, I 100 percent do. I'll start at the top [laughs] and say that at a national level, so CMA having your position, your office, and funding it and supporting it is great. This is still relatively new.

When you start thinking about leadership throughout our province, both at the university level as well as in the hospitals and workplaces, the medical associations, I think that wellness needs to be on the scorecard for all. It just has to be.

The health and well‐being of our health human resource which are all health professionals, the fourth piece in our quadruple aim. Physicians have to be on that. If that was held at that high level, as crucial and critical as for the best patient care, that would be a big difference.

You can see how that would filter down into both the policies that people have, the supports...every place where you would go in and you'd say, "Who's the wellness person here? Who's the chief wellness officer here?" and have that be a norm.

As you come down further, then it becomes about the creativity of doctors which I find is a thing of beauty. Individuals who are so willing to take a chance, I think once we have that happening at a systems level, the creativity of doctors and their want to be able to bring their best self to work and have their best self and some energy for home, that will work wonders.

There's reason to be positive because we have a lot of the information now. At the same time, I worry a little bit that we have to keep the pressure on.

Caroline Gérin‐Lajoie:

Dr. Joy Albuquerque, thank you so much for being with us today to discuss this hugely important topic of the impact of COVID‐19 pandemic on physician, learner, and health care wellness.

Dr. Joy Albuquerque is the medical director of the Physician Health Program with the Ontario Medical Association. Once again, Joy, thank you so much for being with us.

Joy Albuquerque:

Thank you, Caroline.

Caroline Gérin‐Lajoie:

You've been listening to Sound Mind, a podcast about physician wellness and medical culture. It's produced by the Canadian Medical Association in collaboration with Podcraft Productions.

If you are looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca.

I'm Dr. Caroline Gérin‐Lajoie. See you next time.

Transcription by CastingWords