Episode Four
Battling physical burnout
Dr. Caroline Gerin‑Lajoie: Welcome to "Sound Mind," a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gerin‑Lajoie. One year into the pandemic, talk of burnout is common in healthcare.
For Dr. Jillian Horton, this battle began much earlier, medical culture had left her feeling exhausted and unsatisfied, and she longed to find meaning in a profession she used to love.
Her new book, "We Are All Perfectly Fine," is a memoir about her personal journey to overcome burnout, and the ways in which medical culture is failing physicians and learners.
Hello, Jillian, and welcome.
Dr. Jillian Horton: Oh, thank you, Caroline. It's so nice to be here with you.
Dr. Gerin‑Lajoie: First of all, congratulations on your book. It was a pleasure to read and your honesty about your life, about your struggles in medicine hit home.
There were times reading the book where I was laughing it out loud and there were other times when I had some tears. Can you tell us why you decided to write your book?
Dr. Horton: When I think about it, I guess, there are few main reasons. One is, since I was young, completely separate from medicine, I have always had the drive to write.
That's always been something deep inside of me that I knew that it was critically important for me at some point in my life to begin on a path as a serious writer. I did a fair bit of writing when I was an undergraduate and a master's student.
That had been very gratifying to me. That was the first part. It was just a basic artistic drive. The second part had to do with the importance for me of letting stories go somewhere. In particular in my personal life, and you know from reading the book, that my family's journey was very central to my entire life.
Particularly, my story of growing up with two disabled siblings, but especially a sister whom I was very close to, who had a brain tumor, and prolonged interactions many of which were very difficult and unsatisfying with the medical system.
These two things came together in my life. This artistic part of me, the part of me that just hungered to be a writer and my sister's story and so many others that I was just compelled. Those are the two main reasons that I ended up on this path and doing this writing.
Dr. Gerin‑Lajoie: You shared with us that you studied in literature in your undergrad degree and were set to continue along that path. At some point, instead you chose to go in to medicine. Can you tell us a bit more about why you made that choice?
Dr. Horton: It was a tough choice. It was a very big crossroads in my life, still one of the most important ones. Probably, the biggest reason that I decided to pursue medicine was again related to my sister.
I felt that all these things that my family had been through, that I had borne witness to, there was a part of me that couldn't accept the idea that I had this knowledge and this very significant ability to relate to people combined with seeing the importance of those skills in physicians, in particular and the deficits sometimes of those skills in physicians.
I could not leave behind this idea that there was something about these experiences that I had had in our family that there was a part of me that just felt using them in a particular way somehow restored a balance. It made a tragedy maybe just a little bit less tragic, because one could find some kind of purpose in it.
Dr. Gerin‑Lajoie: At the beginning of the book, you talk about the pain you felt in your early days in medicine saying, "Everything burned." One day, it stopped. You wrote, "It was a warning sign and I missed it." Why was this a warning sign for you?
Dr. Horton: One of the things we often talk about, in terms of symptom of burnout is depersonalization. For me, that was how that manifested. I never ever in my entire career have experienced a sense of detachment from patients or a sense of feeling not connected to patients.
For me, personally, burnout manifested is much more...Detachment is maybe not even a right word but indifference to myself. That's what I began to experience from early on in my training, particularly my residency.
I would do anything for patients. I was totally, fully committed to patients. You could see why from my personal story. Why that would be such a defining part of my identity.
I couldn't accept the idea that I would be part of a system that added to the emotional injuries that patients so often experienced from physicians not being compassionate enough.
I felt no such limitation when it came to abandoning my obligations to myself, to meet my own emotional needs, to even meet physical needs, to really tend to my own state. That is what I'm getting at in that section that you that you talk about.
Dr. Gerin‑Lajoie: Looking back, Julian, how would you respond differently if you had been able to recognize that warning sign?
Dr. Horton: That is such a good question. I almost don't even know if I can answer it. What I find so poignant right now is one of the reasons that I'm able to see my life and my emotional responses differently. Now, some of it's age. Some of it's the self‑compassion that hopefully comes with age.
Some of it's different skills. Maybe that's the right answer. When I was...If 20 years ago, I had regular dialogues like this with colleagues, with teachers, with mentors, with friends, with a lot more transparency, and an emphasis not on personal performance, but system performance, team performance, culture of medicine.
Maybe in that setting, I could have handled things differently. One of the things that most of us, this is part of what's best about me as a physician, but it can also be highly maladaptive. When you have something that is so fundamentally important to you, that drives your reason for being a doctor.
For many people, that's a family illness, it was a parent died, or a parent had a critical illness, or there was some of their formative experience that put them on this path. That is what often makes you exceptional, but it's also what makes you vulnerable.
I think that I see that pattern in spades in my own life looking back, and what could have helped me identify that, probably a dialogue and quality of the culture that wasn't present in our training culture, as you know, 20 years ago. I would also add, because I always feel this is so important.
I had some phenomenal, compassionate, highly emotionally intelligent teachers. I had some of the best people I could ever have asked for shepherding me along the way, but the culture was still is, you and I both know, we didn't talk about these things.
I always found that a little bit sad. It motivated me, I think, to create a different space for learners, in particular, when I was an Associate Dean.
Dr. Gerin‑Lajoie: You illustrate very well that concept of shared responsibility, that to create environments that are healthier. It's not just about the individual, the self‑awareness, and building that self‑compassion.
It is very much tied to the culture that we train in, and work in, and almost live in. Thank you for sharing that, Jillian. In writing about your medical training, at one point in the book, you compare it to being like a prison. Can you tell us about why you drew that analogy?
Dr. Horton: The more I've reflected on this over the last several years, what I've found myself struck by is this idea that at one of the most important periods of formation of our adult identities, we enter into medicine. We are spending so much time in many training programs.
The majority of our meaningful waking hours in that institution with those people, including many hours when we should be sleeping, as well. We're just completely immersed, saturated, and initiated into this culture.
It goes on for such a long period of time, that by the time we emerge, there's been so many different life cycles in the event for our families and friends who are in other professions and careers, that were actually no longer recognizable in some ways as the same people that we were.
That's why I found myself thinking about prison as one of the analogies that you come out and you have this element of feeling much more comfortable being around other doctors, other health care providers.
Sometimes, my husband will even say to me, "All you guys talk about is medicine, and you don't even know it."
Here I am, right? I'm a person with a typical background, lots of outside interests, but still, with my physician friends, and mostly physicians have become the majority of my friends, because where else do I spend most of my time?
It's interesting, and I always find that to be a sad commentary that we have spent so many years just totally immersed in everything to do with medicine that what we think we want is escape, but we don't actually know how to escape. We've forgotten how to interact in some ways with the outside world.
Dr. Gerin‑Lajoie: Linked to those thoughts, you've said in the book that many doctors are not part of normal society, and that medicine teaches doctors whole other language. Its scripts are emotions. What we talk about, what we think about, even when we're people outside of medicine. Can you tell me just a little bit more about what it's like for practicing physicians?
Dr. Horton: You make me think of something that happened with a friend of mine recently, who's a physician. They lost a family member.
Talking about this with them, I couldn't help but observe that they were almost apologetic for their grief. This event that occurred in their lives, losing a parent. They were comparing it to..."Well, every day they see people lose parents, and this is a routine thing, and this is part of what we do."
I almost felt as if they had to make an excuse for just being devastated at having lost a cherished parent. I thought that was such a perfect example.
I've seen that pattern before. I've notice strange reactions of my own. I even had an experience recently. It's not the first time it happened. I wrote a piece for "The Globe and Mail" a few weeks ago about healthcare provider grief and loss in the pandemic, and remembered a story from medical school.
I was an elective student, I was in, I think, doing my Master's at the time, but I came and did an elective here in Winnipeg at the children's hospital in infectious diseases.
I was asked to see a baby with sepsis. I went in expecting that there would be a family there, and instead, it was an empty room, a silent room.
I thought, "Well, the baby's not here," and then I went in further, and in fact, there was this tiny six‑month‑old baby lying in the middle of a crib, just listlessly looking up at me.
It was so striking, and I have this vivid memory of picking up this baby, and holding this baby, and cuddling him and sitting in the rocking chair and talking to him. Seeing if I could examine him, and then finally having to put him down, because I knew that my preceptor was going to be waiting to see me.
Putting this baby down and him crying and sobbing in the crib as I walked away, and just what that feeling was like.
When I was writing this article, and I showed a draft to my husband, my husband was haunted by this story. He said, "That is just such a terrible story," and I was like, "Really?" I know it's sad, but that is not even top 500 of the terrible stories [laughs] that you or I would have from our training, right, in terms of the saddest things that we saw.
I thought about that, too, that sometimes the reactions that people reflect back to us. You remember the story, but you can't remember every single one of those cases as something that affected you emotionally.
It's curious, seeing that it sometimes takes other people's reactions to remind us this is a really terrible story. This actually was a really traumatic, or very sad, or very unusual thing that the average person would be quite affected by.
That's another reason, probably, that physicians should have more non‑physician friends [laughs] and more people in their circle, because we lose the ability sometimes to be that reality check for other people, because we're no longer fully immersed in other people's reality.
Dr. Gerin‑Lajoie: Certainly, it helps to keep us grounded.
Dr. Horton: Yeah.
Dr. Gerin‑Lajoie: You eventually decided to go to a mindfulness retreat for physicians, which you write about in the book. You write about being very skeptical. Why were you so skeptical, Jillian?
Dr. Horton: [laughs] Well, I think that I am a lot like the average physician when it comes to my preliminary attitudes, what they were in terms of mindfulness, in terms of physician directed initiatives for people who are burnt out.
I thought the exact same thing that people now say to me, "I'm not the problem. You're saying I'm the problem? My skills are the problem? The system I work in is totally impossible. It's crazy making. It's illness inducing. Now you want me to go in, I'm supposed to fix the problem?"
I had that exact same kind of knee jerk emotional reaction to the idea that mindfulness or meditation could be helpful. I felt affronted by that. I had that initial reaction, "Come on, give me a break!"
As you know from reading the book, I was lucky, it just so happened in Winnipeg that one of the program's two creators was passing through here giving a workshop. I went to the workshop. I thought it was good. I just spontaneously decided, "You know what? I'll try."
I had an educational budget working at the university to go and do that kind of training, and I hadn't done anything like that in years.
My youngest child at the time was not even three. It was a big change, also coming out of those really intense years of motherhood. I had three kids, each two‑and‑a‑half years apart, so that was coming out of that decade where you're just beginning to consider, again, what you might be able to do that is for yourself and for your own career.
All those things just combined, and I took a chance, not really expecting it to be anything other than a trip and a funny story to share with friends afterwards that we could all roll our eyes, and boy, the joke was on me, because it really did end up changing my life.
Dr. Gerin‑Lajoie: How did it change it?
Dr. Horton: The first thing, I think, Caroline, is I let my guard down. Even though I'm a highly emotive person and very comfortable having deep conversations with people about philosophical things.
I remember what we were saying at the beginning, there were a lot of those things that I had no trouble applying to other people but I really struggled to apply them to myself. For the first time, again, just to go back to that story of my mentor Brandon, saying, "Why didn't you tell me?"
The first time that I really felt able to engage in conversations with colleagues about how much weight I was carrying from feelings of my own inadequacy. Feelings of failure.
Silly stories that had a lot more to do with my ego, or my own feelings of helplessness at the time. Not silly, but stories that had a disproportionate impact on me compared to what the events actually were.
I think one of the reasons I was able to let my guard down is actually the nature of what mindfulness does. When we start by meditating and doing focused attention practices, we increase our vagal tone. The people around us, if they're doing those activities, they increase their vagal tone. We get this polyvagal activation, and everyone feels a little bit better.
You're feeling nice, positive, compassionate feelings for one another that are coming out of this fundamental physiologic activation. All of a sudden, it's a lot easier to start talking to people in a meaningful way.
If you think about the clinical environments that a lot of us work in, there's not a lot of polyvagal activation. [laughs] There's all other kinds of activation, but we're not sitting there in a relaxed, positive, blissed‑out state having prosocial feelings towards one another. I don't think that describes a lot of clinical work environments for physicians frankly, then it describes some of them. It doesn't mean there aren't some good relationships, but it's a vibe, it's an atmosphere that is created.
That becomes the base for not only learning some of these self‑regulation skills, but also for having meaningful conversations around some of our key pain points. That's the other really magical thing about this program, this retreat. It's that you can just jump right in.
I was talking to someone about this the other day, and I said, if you just imagine, it's not that the group has to be homogenous, for this transformation to occur, but when we meet together as a professional group, we don't have to explain what it feels like to feel helpless when a patient is dying in front of you.
We don't have to explain what it's like to go home from work thinking that something that you missed, that somebody is no longer alive because of that, because those are generally experiences that...Again, it comes back to that prison idea or that initiation idea.
It's hard for people on the outside to really get that. All those things combined allow for this experience and this kind of experience to be profoundly life altering for people who participate. That's how I would describe its impact on me over time.
Dr. Gerin‑Lajoie: Do you have any examples of how it has changed the way you practice medicine?
Dr. Horton: Yeah, one of the most concrete examples traces back to something that I like to talk to learners about when trying to help them understand how meditation, or focused attention practices, can actually help us.
It's a study that I read about looking at the physiologic reactions of meditators and non‑meditators. Exposing them to something like a really loud noise or a gunshot and looking at their physiologic responses. What we see is that initially for both those people, they'll have the same response.
They'll have the same cortisol surge, the same catecholamine rush, the same rise in their blood pressure. The people, in general, as a trend, who are meditators, the people with the focused attention practice, will go back to baseline more quickly.
That is one of the best concrete examples for me of how I've seen in real time how this work influences me in a clinical setting.
The experience, you'll be on the ward, there'll be a code blue or someone will come and grab you and say, "I can't find a pulse on so‑and‑so." You'll rush into the room, and sometimes the patient is sleeping and everything's fine, [laughs] and other times, it's a real emergency.
What I've noticed is just how quickly I seem to return to my baseline compared to before. Something would happen and I would stay in that aroused physiologic state for a really long period of time.
I'd notice that I was tense, or I wouldn't even notice but I would feel bad in a way that I couldn't really articulate or describe. Things will still get me agitated, irritated, whatever, but I'll settle. That's what I've noticed with doing consistent bursts of meditation, breath work.
I mean short. When I'm on a clinical service, sometimes I'll do 15 minutes interspersed throughout the day. Five minutes here, seven minutes here, three minutes here. It's not sitting in an hour in a lotus position on my office floor.
I just notice, even right now, I've conditioned myself that doing a few minutes of breathing or guided meditation in the morning, I'll notice a few hours later, I just feel better. That's one really concrete example.
I think other things. I've noticed that it's easier to listen. Some of why it's easier to listen is because I'm a little better now at noticing what's happening in my body, in my mind, in my thoughts. The noticing...our attention is always wandering.
Our thoughts are always going off in the distance and then we're redirecting them back. The work that I've done in the last several years has simply made me more aware of that.
I find I feel more connected to patients as a result. I always thought I was a good listener before. Now, in a clinical setting, I feel even more present with people, even more in touch with my emotions. If something annoys me, I noticed, "Yeah, I'm annoyed."
If I'm having some kind of a negative feeling towards a patient, I notice it. It comes and goes instead of me trying to change it or get away from it. The same thing is true for positive emotions. Unequivocally, there is more joy in my life, that I laugh more easily, that I smile more readily.
I noticed the texture, and the nuance of good things that are happening during the day and feel just a little more capable at tolerating the things that we would think of as challenging or noxious.
Dr. Gerin‑Lajoie: Now, Jillian, the events in your book all happened before the pandemic. Since the pandemic began, there's been a lot more talk publicity, about the stress‑facing doctors and health care workers. Do you see this pandemic changing attitudes about burnout and medical culture within our medical community?
Dr. Horton: I think the short answer is yes. I think that this will be, for us, a tipping point. There is no way that after this, we will be going back emotionally, culturally, and maybe even physically to business as usual.
I think back on my own life, and the most difficult experiences, like I was saying at the beginning, the hardest things in our lives, are often the origin of some of the best things about us. We are going to look back at this horrible time in history.
There's going to be a lot of trauma and a lot of brutal things that we'll all have experienced and a lot of memories of sadness and loss and everything else. I do believe, we are also going to be able to look back on it and say, "This was finally the moment when we realized we are human."
We cannot push our physiologic boundaries, the way that we have historically done in medicine. We need sleep. We need rest. We need food. We need emotionally healthy environments to work in.
If we are going to continue to pretend that we don't need these things, the evidence is going to continue to become more stark, that the people who or the subspecialties that reject that change, that their performance is impacted.
Gradually, it is going to become clearer and clearer that their views are no longer contemporary. The pandemic will end up forcing our hand. We had so little reserve going into this as a profession overall. It is going to force positive change. None of us would ever have wanted it to happen in this way.
It was coming anyway. We were slowly inching towards that tipping point. I do believe that the effect of the pandemic will be to accelerate our sense of urgency at rectifying some of the cultural problems that have plagued us as a profession.
Dr. Gerin‑Lajoie: On that note, are there other things that you feel we need to change in our medical culture?
Dr. Horton: There are so many. We clearly need, in medicine, more equity, more diversity, more inclusion, and more opportunities for a sense of meaningful belonging for people who are represented in any of those groups.
Medicine has so many problems on that front. Then again, many people are doing important work around it. The events of 2020 have really accelerated our reckoning with racism in medicine, with paternalism in medicine, and with so many other bad‑isms [laughs] that have defined our experience.
The other thing that I hope will continue to evolve and change is what I've seen so much of in the last 20 years, the time that I've been a physician anyway, our conversations about how do we stay compassionate, how can we be compassionate when people are taking so much from us when we give, give, give.
I hope that, along with all the other change that needs to occur, there will be a reframing of what our role is, a return to the concept of service that we would reconfigure that to reflect everything that we emotionally get out of this profession. That, of course, is a problem. We've cut ourselves off from so much of that, that no wonder we feel that way.
If you see the patients as being there to be kept at a distance and all the difficult emotions associated with their suffering and their death as being things that you have to wall off in a containment room, no wonder it's not accessible to you to be able to tap into the sense of replenishment, or the sense of the positive reinforcement that comes when you are compassionate and patients are so grateful.
They are so kind. They are so loving to you in return, and when we don't get to experience any of that, I don't know how anybody could do this job without that side of it, frankly. I'd see that as one pattern of practice that I'm sure you recognize too.
People who don't treat medicine as relational, no wonder they cannot even stand to go to work because frankly, on the very worst days at the very lowest points, that's the part of it that sustains me.
I hope a real profound return to this idea that we really need to reconfigure how we framed professionalism because we've inadvertently led a whole generation of learners to believe that professionalism means leaving your personhood at the door and being very formal and perfunctory with people, and that was a well‑intentioned movement.
There's a lot of important concepts that fall under the umbrella of professionalism, but many people had a fundamental misunderstanding of what I think it was the profession's hope to communicate in that movement.
It's also fuelled on a very personal level, a sense of detachment, a sense of disappointment, a feeling that this profession is not aligned with what we thought we were joining when we went into it in the first place. I think we see more and more attention being paid to that relational aspect. That's another thing that we're beginning to notice, is having a renaissance.
I'm hopeful that that is something that we are going to hear more and more about in our professional future.
Dr. Gerin‑Lajoie: Where do you think that change should start from?
Dr. Horton: Organizational factors are the primary drivers of burnout. Within organizations is culture, and culture, like organizations, they're still aggregates of people. They're still the total sum of the people working within those systems.
What happens over time is they become more powerful, but when we begin to change, we're reflecting that other part that we can influence. The locus of control that we can find in our own behaviour, in our own reactions, in our own attitudes. Something that is much more difficult to measure begins to happen.
To me, what that is, is we go as these people who have been a little bit changed, who have augmented our skills, who have broadened our perceptions, and we go back, as leaders who are tasked with changing some of those things that fall under the 80 percent of the system factors and organizational factors.
Personal change is a powerful tool. It is not the only tool, but at the same time, personal change can occur relatively quickly compared to system change. The strategy, and this has been very profound for me, learning new skills, making my own quality of life better, controlling what I can control.
Taking those in my different roles of leadership, of administration, and beginning to teach those skills to others, as well as working on all these other things.
Working within my department as an associate head, working on professionalism and equity and diversity, and teaching, and being a fixture for many years in the learning environment and one by one supporting students.
That's part of system change, too. It's this personal work that has allowed me to continue to tolerate the difficult environment and go forth and make that change. To me, I don't know how else we tackle this because the only way we can change the system is to continue to work within it.
We have to build up that psychological personal PPE because they're just...to me, there really isn't another formula for us to continue to work within the system.
Dr. Gerin‑Lajoie: That's a very inspiring call to action. Jillian, thank you so much. It's been really a pleasure to have you here and to use terminology directly from your book...it is now time to 81 you, so the readers will recognize exactly what that means. Thank you and good luck with the book, Jillian.
Dr. Horton: Thanks for everything, Caroline. Thank you.
Dr. Gerin‑Lajoie: Dr. Jillian Horton is a general internist, podcaster, and award‑winning medical educator. Her book, We Are All Perfectly Fine is published by HarperCollins Canada, and is available in bookstores now.
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're looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca.
If you're a physician or medical learner, or one of their immediate family members, counseling, and access to mental health supports is available at cma.ca/supportline. These are especially difficult times, and I encourage you to ask for help, regardless of how big or small the challenges you may be facing.
I'm Dr. Caroline Gerin‑Lajoie. See you next time.
Transcription by CastingWords