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Jessamy: Hello and welcome to The Lancet Voice. I'm Jessamee Bagonall. 

Gavin: And I'm Gavin Cleaver. It's September 2021 and we're very pleased to have you on board. The mental health of people working in health professions has been at the forefront of all of our minds during the COVID 19 pandemic. But mental health issues have always been a problem in the healthcare world.

In The Lancet this week, there's a review of the evidence around the mental health of physicians accompanied by an editorial. Some of the conclusions are striking. In low and middle income countries, there is very little research to go on. But in high income countries, where studies have been performed, rates of depression, anxiety, post traumatic stress disorder, and alcohol use tend to be higher than in the general population.

In the USA, estimates suggest one physician dies by suicide every single day. To talk about this sensitive topic, Jess and me spoke with three people from the Temerty Faculty of Medicine in Toronto, who run interesting physician wellness initiatives. First you'll hear Pierre Bryden, Senior Advisor for Clinical Affairs and Professional Values, and Julie Magie, Director of the Postgraduate Wellness Office and the COVID 19 Faculty Wellness Coordinator, and also Lisa Richardson, Associate Dean of Inclusion and Diversity.

Jessamy: All right let's kick it off then. So maybe you could tell us a little bit about this sort of historical context of physician well being, some of the research, where it started. Whether it's new and guess where it's headed. 

Lisa: So the majority, I think probably, that the majority of the early work in physician wellbeing really focused on the individual and the responsibility and the role of the individual and maintaining the wellbeing.

And if you look at the literature, it's really just in the past. 10 years that we've started to move a bit away from that. So all the original literature there's still ongoing literature in the, looking at the individual, but initially all the intervention data really was individually based.

Probably around 2015 2017, there emerged a few seminal articles that looked at the organizational approach to physician well being, and in particular tried to understand what the key drivers were that contribute to being and conversely burnout, and what Those articles showed what is that the factors that contribute to being are largely situated in the workplace.

And then the other key thing that started to really come out in the literature around 2015 2017 was the central role that leaders at all levels of the organization have on being able to maintain people's well being and preventing burnout. And there really, there was an article in 2015 out of the Mayo Clinic.

That really that looked at some of the factors that characteristics of leaders what those characteristics were and the impact that having those or conversely not having those had on the well being of the people who reported to the leader being studied. So more and more, we're really seeing this level of literature emerge.

I think that looks at leadership and organizational factors, wellness 1. 0, as I said, was really looking at the individual wellness 2. 0. If you watch people's response to wellness 1. 0 was that it's. All the organization or it's all the system. And I think now wellness, what I like to call wellness 3.

0 is really trying to understand that it's not one or the other, but it's a complex interplay between the individual. Working in an organization, existing in a system and being embedded in a larger cultures. And I think it's in being able to consider that complexity that we start to find the solutions.

Jessamy: That's great. And just picking up on some of the words that you've used there in terms of risk factors, what are the sort of generally agreed risk factors for problems with professionals, health and being? 

Lisa: So that's a good question. So in the workplace, the things that we've started to identify and study are what we would call, the dimensions that drive either well being and engagement, or conversely, burnout.

And they are things like things you might expect, like workload, job demands efficiency and resources in the workplace. But also things like Social support and a sense of community and belonging in your workplace. The organizational culture and values the ability to integrate your work with your personal and, home needs and the degree to which you have control or flexibility in, in your job and in your workplace.

And a lot of those really impact on people's sense of psychological well being and psychological safety in the workplace. And those, those together I think are largely related to or thought to be related to, people's either, again, being and engagement and amount of vigor they have at work as compared to being burned out.

And so I can just add that one of the areas that we work on closely together is when we think about community and belonging a lot of that is also impacted on by the area of, inclusivity and who do we include in our workplace? And what do we need to be doing to make sure that everyone is included and welcomed and heard and that's one of the areas that we try to work on together.

Jessamy: Could we talk about the relationship between professionalism, physician being and inclusion and diversity? 

Julie: I, when I think about well being and when I think about the experiences of physicians and healthcare practitioners, particularly during this pandemic, which is exacerbated. I can't help but coming back to that word of inclusion, because inclusion means that you bring your full self, your authentic self to the space where you are working and learning, that you can be whomever it is.

You're not having to put on a mask. You're not having to hide your identity. So that you're not in this, you're not having to perform, so to speak. And the issue is that in medicine, although we have tremendous diversity, we haven't had inclusion because we've had the norms of behaviors, the norms of practice, the norms of leadership, the norms of even how one interacts with people.

One another and our patients being determined by a particular group as such that others. Have not seen themselves represented. So that when you're walking into a hospital or university setting, if you, in my case, come, as an Anishinaabe Indigenous physician, coming into this place where you're not seeing yourself represented, and you're also seeing what's being rewarded, as being this particular model, which is not yourself.

There's this disconnect so every time you're everything you do in your work environment means you're in this You're not able to be yourself. There's a little bit of there's a mask that you're wearing and so add to that in particular For those from structurally underrepresented groups and marginalized groups in medicine, we have a focus on Black and Indigenous learners and physicians because of the massive disparity in health outcomes.

But of course, many other communities are represented there. We realize that we're not supporting our clinicians and physicians and learners with disabilities. But when you're coming into these spaces, not only are you not feeling, seeing yourself represented or feeling supported. You are carrying this extra burden of having to do the work of supporting in their well being because you are in the institution and people are looking to you.

So we call that the minority tax. It's well described in the literature. So you're carrying all of this extra burden. And then additionally, you're carrying what's called a stereotype threat, where you're afraid that if you misstep, that you will represent the whole community, so that no one will ever want to hire another black physician with a disability, trans physician.

So that those are the extra layers and why we realized that we couldn't possibly engage in this work without recognizing. that intersection and those identities. So we do work around mentorship and support. Our offices are working closely together so that when we see that there's been, for example, a professionalism concern that's brought forward, is that simply a person who's having to speak up about an experience of racism?

Or an injustice that they've observed. Or is that person experiencing, like what we call racial battle fatigue, so they're exhausted and they're, supporting doing a whole bunch of extra work that's not recognized by the institution that may be leaning, leading to burnout. So we really have seen, I think, a need to have that.

holistic perspective and understanding of well being and how to support those. Because what I always say is when we lift up the well being of those who feel most excluded in our system, we're creating actually supports where everyone can then benefit from thinking about well being in a more holistic way, not just mental, physical, but emotional, spiritual health as well.

Thinking about it not just at the individual or institutional level, but how we're connected to community. All of that will really help more broadly, we think. That's some of the intersectional work that we're trying to do. 

Pier: And just to piggyback on what you said, Lisa, I think in many health care facilities, professionalism has become seen in quite a negative light.

It's the professionalism police and it's the stick that we're going to enforce conformity. And I think that's where your point Lisa about, we really needed to redefine that for our faculties and learners around inclusion. And it's not about you become this individual who suddenly looks closer to the current leadership and power, because we know there are gaps between who our leaders are and who our early career faculty and learners are.

But We're actually looking at creating environments that encourage you to bring your full self to work. So I think that was a really important rethinking of professionalism, how far we've managed to be successful in conveying that to our faculty and learners, I think was still fairly early on, but that's that's one of our major goals.

Jessamy: So interesting and important, I think also because From a sort of more international perspective, I think there is a growing narrative about the dark side of professionalism in terms of that conformity and how we address that and the conversations that we need to have, on a really sort of societal level is very interesting.

And why do you think these conversations around physician wellness and professionalism are difficult to have? They sometimes feel uncomfortable. 

Julie: I can definitely comment a little bit around that because I think it grows out of what I was speaking about. We have, what is the construction of the good doctor.

Who is a good doctor? We have been told that a good doctor is infallible puts your head down, works really hard, gets through it all, the, has the discipline, resilience, ability to be super woman at home, at work, caring for other community, advocating, publishing. That is still the narrative. And so when one steps outside of it, it feels like you're letting down your profession, your patients, your family, and yourself.

In a way, there's been this culture of silence around around fallibility. And to me, this is about being human and about actually those moments of having experiences when you need to care for your own well being are actually what we should be doing, what we should be thinking about for our patients as well.

But we've always separated ourselves. from that. So when you come forward, you're scared. There are repercussions about your job, about your disability insurance, about your potential to progress academically, to be considered in a leadership role etc. So I think that's been certainly one of, one of the concerns that I've seen.

Lisa: Yeah. And if I can piggyback on that, these are very real concerns that people have observed over generations, right? And I think for us to come out and say, we're not well, or we need to step away, or we need to do better. So X, Y, or Zed to take care of ourselves. So to, to do the individual things we need to maintain our well being really risks.

I think people see it happen every day, right? It risks your reputation within medicine. It risks your concerns about being promoted. It risks how you're seen by others. And so these are, there's so much telling us not to speak up about this and not to take care of ourselves that we have a lot of work to do to turn that around.

Jessamy: Yeah, I think shifting the focus from omnipotence and deprivation to one of self care. They're polar opposites, so it's a long way to go. It's difficult. It encompasses everything else, our families and the way that physicians live their lives. Applying a gender lens also, it's, things are changing.

And I wonder what you feel about That aspect of it, the profession is changing in terms of diversity and who is, who's joining it. Certainly post COVID 19 I'm sure there will be further changes. There seems disparity in our thinking and who is actually. Coming into the profession. Now, how do you think we bring those together?

And is there some urgency to it? It feels like there is some urgency to it. 

Lisa: I think there is an urgency to it, right? If you look at if we looked at the data just in COVID 19 on some, some of the data that we Looked at locally and the the literature, the published data also reflects this, that women, for example, are have been disproportionately affected in the, academic medicine and looking at our local data, the most, one of the most common sources.

Of stress and request for support with was child care during the pandemic. And so it's hard to imagine. I find it hard to imagine how we will emerge from this pandemic without actually addressing this with urgency. 

Pier: I also think it's quite a radical agenda. If we think economically, we've really downloaded historically a lot of the costs.

onto the families of physicians and physicians themselves. I'm still speaking about physicians, but we're clearly seeing through the pandemic, this is also true of nurses, of other healthcare professionals. And I think as we have more data, around the cost that has had for healthcare professionals exacerbated by the pandemic and more people willing to speak up as a result.

We're starting to realize this would be a major redesign and in some cases expensive redesigns and others. I think. Perhaps, if we really do this well, not so much, and there could be some long term gains, but, things like our depth of staffing for our health care units so that it's not a major issue for your team if you're ill and you need to stay at home.

Job shares, leaves disability insurance, these are all things with dollars attached and quickly become politicized. And as we talked a little bit of earlier, physicians had historically a bit of a generalization, but often. position themselves outside politics. And so now, if we're really going to make changes that we see, are for the good of not all healthcare professionals and therefore patients, we're really entering the political fray about where do we put our money around our healthcare institutions.

Are we salaried? Are we not salaried? How do we staff our training programs? How do we staff our consultant faculty levels? Do we provide on site childcare? These are major political and economic decisions that positions are starting to advocate for. 

Jessamy: So maybe that could move us nicely on to, what role other sort of external forces Not really external, but larger forces, medical regulators, educational colleges, health bodies, what role do they have in this?

And where do you see their input being? And do we have examples where there is some movement already? 

Lisa: I can make a comment about medical regulators, I think. And I make this comment partly from having the experience of talking to a lot of physicians and partly from Looking at what's in the literature and I want to preface it with it's not an easy job.

I think to be a medical regulator because you're your primary focus is to ensure the safety of the public, right? And without question that that has to happen or, that the public could be at risk. Now, that being said, I think that we have to be I think we have to be open in medicine, which is still self regulated where we are anyways, I think in many places in identifying where there are structural barriers or structural stigma is built into the ways in which we Ask questions about people's health and being the ways in which we monitor people's or physicians health and being so that we are not inadvertently stigmatizing those with certain kinds of disabilities or certain kinds of health difficulties because it's not everybody with a certain diagnosis, for example, that needs monitoring, right?

So those and those for whom it impacts on their ability to take care of patients safely, arguably would need some kind of monitoring potentially to ensure that they were still safe in the workplace. But that isn't that's not everybody. So I think we have to be very, um, courageous in having these discussions about where there are some, there's built in structural stigma and be able to look at those and advocate for the changes that that may need to happen.

Lisa, I'm sure has, you could probably add more to that and Pierre. 

Julie: I just, the whole conversation. around professionalism when it's linked with regulators as well is constructed from a punitive approach. All of these conversations are deficit based. And how do we flip The approach and the structures to actually move to a strength, what I would call a strengths based approach where expressing your vulnerability and recognizing and knowing that you may need help becomes something that's a marker of success.

your insight, your self care, your self knowledge, and where you in coming forward can be supported and coached around what you need to thrive, as opposed to being in an environment where the moment you acknowledge there is a concern, then you're worried about how it will be managed and handled. And so we just are perpetuating that model.

So it really is for me, a rethinking of the way in which we imagine this, where, you know in, in other communities and environments, actually, that self knowledge is considered. a tremendous gift to have that level of insight and to be aware of when you're reaching your limit and wow, like maybe I need to take a little time off.

I've got a lot going on. I really see that because how and I see that when I look at the work of regulators around. patients bringing forward concerns as well. What I hear from indigenous patients and black patients, they are they don't want to go through a regulatory process and bring forward a complaint because that process itself feels so traumatizing as opposed to a restorative model.

How do we move from Punishment to restoration in these conversations in the way in which we look at this work.

Gavin: Thank you to Pierre, to Julie, and to Lisa for talking with us about their initiatives and work. As I mentioned in the introduction, a review in this week's issue of The Lancet looks at the evidence for physician mental health issues. Jessamy also spoke with the author of that review, Sam Harvey, who's the Deputy Director of the Black Dog Institute in Sydney, Australia.

Jessamy: Perhaps we might start by you just telling us a bit about your day to day work and how you became interested in this particular topic. 

Sam: Okay. I'm a psychiatrist and at the moment I'm the acting director at the Black Dog Institute. So the Black Dog Institute's a independent medical research institute.

We're based in Sydney in Australia. We've got about 250 staff members and What we aim to do is we aim to do both research and then the practical applications of it. So within our staff, yes, we've got lots of researchers like myself, but we've also got the people who go out and do their education in workplaces and schools, the IT teams that develop our apps and clinical services.

And one of the research streams we have is the workplace mental health stream. So really focusing on that link between work and mental health across a range of different groups, including health professionals. 

Jessamy: The evidence base in this area that there wasn't any evidence 15 years ago, how far have we progressed?

Sam: Do you know, I think one of the things that, that really became clear in writing this review and probably was a big part of the reason why we wanted to write it. I think. What's progressed over the last couple of decades, there's no doubt where there's greater awareness of this issue, particularly amongst health professionals and physicians in particular, we're talking about mental health of physicians more than ever.

But actually, we've struggled to get past that conversation. And so what, there is an abundance of cross sectional surveys. It's documenting just how common symptoms of depression and anxiety are amongst physicians. So I really don't think the world needs many more of that. We know the sort of what's going on.

What there is still a real lack of is understanding why. this is going on, why it's changing over time, and what the solutions are. And I think that's an area where health professionals have really dragged behind other occupational groups. Other occupational groups have shifted to say, okay what do we need to be doing to solve this problem?

Whereas we still know surprisingly little about that. I think the other big gap that's highlighted in this is how little we know about low and middle income countries and what's going on with the health professionals there. There's ample reason to think that what we're seeing in developed countries will be, that those same problems will be even greater amongst those workforces in low and middle income countries.

But there's just so little evidence out there. It's really, was hard to say much about that in this review. 

Jessamy: Yeah, I was about to ask, because it's a small section, isn't it? But, is it reasonable to think Do you think that there are similar things going on or do you think that it's very culturally or region specific?

Do we have any idea about that or is it just speculation? 

Sam: Look, we know a little bit about it. We know that when of the studies that have been done, particularly looking at doctors in training, when they've looked to see if there were major differences via region, there didn't seem to be.

But of course, Part of that was because there were some regions that there was so little data, they weren't really able to be included in a meaningful way. Um, I think there is, clearly there is probably something about many of the doctors. I think there are different factors that drive people into a career in medicine in different cultures.

And so I think that is probably going to be important. All the types of things that we know seem to be risk factors for doctors having mental health problems in terms of where there are work related risk factors, things like the number of hours they're having to work, the impact on their life outside of work, the degree to which they're supported.

All of those. factors are off the charts within low and middle income countries. So frankly, it would be amazing if there weren't these problems there. The one thing that may help mitigate against that is there's a lot of protective factors. In workplaces for doctors a lot of in terms of that sense of purpose in what you're doing, being part of a community seeing immediate reward in some cases.

And I think what's interesting, if we look in developed countries, a lot of those things have been chipped away. for physicians, and perhaps that hasn't occurred to the same extent in low and middle income countries. And so it might be that even though the risk factors are greater there, some of the work protective factors have moderated the impact of that.

But that's largely speculation on my behalf. 

Jessamy: So what does your review demonstrate about physician well being? 

Sam: One of the things is that if you look at a group of physicians, really in any country where they've been studied, you're going to find about 30 percent of them are reporting significant amount of depression or anxiety symptoms.

That's actually pretty similar to what we see in other occupational groups. So in terms of the amount of mental health symptoms amongst physicians, It's not that there's clear evidence they're at increased risk, but there's pretty overwhelming evidence that they're at similar risk to other work groups.

And that may seem like a bit of a nothing conclusion but in a way it's important because I think many of us, when we were training as medical students, There was an implicit assumption that we were somehow immune to mental health problems. So it's clear that's not the case. It's also clear that it's not a rare problem, it's a pretty common problem.

I think the other related figure which is really important for us to come to terms with is even though the level of Symptoms are about what you would see in other similar working groups. The rate of suicide amongst physicians is higher than just about any other occupational group. That's not being driven by increased symptoms, it's being driven by probably partly access and knowledge around ways to end your life, but also I think about the barriers for physicians being able to get help when they need it.

And we've got about a third of our doctors out there with significant levels of symptoms for many of them that will be transient and they don't need any mental health intervention as such. But for many of them, they will. And I think what we're seeing is the consequences of those barriers that we put about them being able to get help when we look at the suicide rates.

I think the other real headline that I would pull out is that there is a bit of evidence that things are getting worse over time. And I think that fits with a lot of anecdotal stories but there now is a bit of data that certainly Over time, there seems to have been a gradual increase in the amount of symptoms being reported.

It's not yet clear whether those rates of suicide are changing over time. There's some evidence from some countries, but that's, a real lag indicator. And I think that really pulls us into, in a way, The more important question around what is going on in physicians workplaces that is firstly leading so many of them to have symptoms and then secondly might be causing it to be getting worse over time.

Jessamy: We're hearing a lot, or I've been hearing recently about this sort of silent epidemic of physician suicide in the States. Do you think that there are the rates there much higher than elsewhere or is this something that we're just becoming alive to really and just understanding what, what's going on in different places.

Sam: The evidence is, it's the overall pattern of physicians having mortality rate relative rate of about one and a half compared to what you'd see in the working population is pretty consistent across countries. There is some data from some countries suggesting that things that the relative risk of suicide might be particularly high for female physicians and that might be something that's changing over time.

My suspicion is that rather than there being an epidemic, what there is a sort of an unmasking of what has been there for a while and that now we're just, we're talking about a bit more. We're noticing it. It's being reported. And yeah, in the States it's that some of the figures we quote in, in the paper are quite startling where we've now got one physician dying by suicide every day in the U.

S. We can't keep looking away from that. 

Jessamy: And you raised some recommendations in the review about what, things might be able to change and how they might, make things better. How easy do you think they would be to translate? Can you walk us through them and how easy do you think they'd be to implement?

Sam: There's a spread of how realistic some of these things are to be able to do in the short term. But in a way, as I mentioned at the start, that was my real motivation for wanting to write this paper because I think we're at that stage where there's this increased awareness about mental health amongst physicians, but I think there's a risk that at the moment there's a lot of initiatives happening in hospitals and in training programs and in medical schools that are motivated by goodwill, people wanting to do the right thing.

But they're uncoordinated and often they're not aligned to the research evidence of what works. And I think sometimes they can be problematic and there is a real risk that if we just think the answer is mental health awareness, that, that can actually increase the problem. And I've seen medical students who have come to me and said, Oh, we had a lecture about.

Yeah. Physician, mental health, and I'm now terrified that I should pull out of medicine because I'm going to become unwell because of these scary stats that I've seen. And this is one of these examples where I think we in the medical profession can look at other occupational groups and say, okay what's, what has worked?

Um, there's no magic bullet here. You need to be doing coordinated stuff and it needs to be beginning in medical schools and carrying on through it throughout the health system. And one of the things we talk about in the paper is the need for a systems wide approach and what that means is that there is stuff that we need to be directing towards individual physicians.

But there is also stuff that has to be happening in the health system and there's also stuff that our professional training colleges and regulators need to be doing and all of those things are important. Something which I hear doctors rightly rally against is what often happens in addition to what I consider to be slightly pointless soul mental health awareness training, just operating in isolation, is then it suggests, oh, the solution is resilience training.

Let's make our doctors more resilient. And of course that's, that implies that the problem is that somehow they're not resilient rather than actually addressing. The factors that are causing the problem. So perhaps what would be helpful is I give an example of some of the stuff that we're saying needs to happen.

So even though I think we need to be very careful to say. The whole answer to this problem is to make individual physicians more resilient, that's not the case. But, I think there is stuff and there's reasonable evidence around what you can do with individual physicians, and that has to start in medical school.

What used to happen was that nothing was said about it, clearly that's not good enough. Then we've been through a period where medical schools just want to roll out mental health awareness campaigns. I don't think that's good enough and we know that they don't really work. What we need to be doing is embedding.

Practical skills within the training of our doctors in medical schools around teaching them active coping skills, normalizing help seeking, normalizing looking out for your peers. And then that needs to be reinforced in the early years. We know there's a big spike in mental health symptoms during intern and junior doctor years or residency years.

That's partly because that's the natural history of mental illness. That's the age group that people tend to first present with significant symptoms, but it's also because they're really stressful times. And there has been. A small number of studies that have shown that you can teach cognitive behavioural mindfulness skill to doctors and that it does make a difference during those risk periods.

And we summarise some of these in a separate review and meta analysis we published in the Lancet Psychiatry looking at that. So that's part of it, but actually. I think where the money really lays in this question is looking at what's going on in the health system and that's a great gap and what's extraordinary is we know that's where the risk factors are, we know it's about working hours and about the increased administrative burden, the lack of job security and all of those things.

are things that, that it's a health system that, that can adjust. And yet when we've looked at the literature, there's not a single control trial that has tested some of adjusting some of those health system factors and the impact that has on. Physician mental illness, there are a couple of studies out there about physician burnout and that they show how effective some of those things can be.

We haven't even got to the point of being able to test how those organizational level shifts in a health system can impact on physician health, but we know that's where the greatest gain is going to be had.

Gavin: So just me, I really loved those interviews. One thing that really struck me from them was Sam saying in his interview that this kind of. The kind of chat about physician well being now is a non masking of the problem that, now we're talking about it more but it's always been there.

What do you think about that? 

Jessamy: I think absolutely it has always been there. There's always been a tension and a pressure between the desire to look after your patients and the need to keep yourself well. And that's not just for physicians. I think that spans over all health care workers. This is the year of the International Year of Health and Care Workers.

We've written about and talked about that before this year, but these are people in society who You know, do sacrifice an awful lot of themselves and their families to look after others. And, of course, there's tension there. I think, some of the discussions that we've had around professionalism, there has been almost a need to build up this set of values, which means that is the sort of received wisdom of what the role of a good doctor is.

is about self sacrifice and serving humanity. But, that has a very paternalistic backdrop and is very traditional and it's based on a health system which is no longer really the reality of what people work in today in terms of investment, numbers, demand. Those conflicting aspects, I think, have heightened the difficulties that people face.

Gavin: I was going to ask you about that characterization, actually, because it came up in the first interview, didn't it? Lisa was talking about it. I found it very interesting. Would you say it's outdated? And I guess How should people be thinking of doctors, healthcare workers, health workers now if it's not in this kind of self sacrifice type vision, I 

Jessamy: mean, that's a good question and I don't have the answer to that. It's something that we need to modernize and we need to question and ask ourselves really on a societal level because These are issues that feed into our set of values that we have on a societal level and how we invest in things and how we approach things.

I think there is this growing narrative now in healthcare and before in other professions about some of the dark sides of A professionalism, particularly I think in other professions where people have been called unprofessional because maybe they're calling out something which doesn't fit with their set of values or is a sort of historical backdrop and that it's easy to label that as unprofessional.

In an idealist world, the professional is this set of values that gives the public trust in doctors and trust in healthcare workers. But it has to be a two way system and that, those set of values can't harm physicians or healthcare workers. I think that's the situation that we're in now, and we need to re evaluate them.

Gavin: Do you think it's possible to get a similar health service which takes less of a toll on health workers? And I say this especially in light of obviously COVID taking a massive toll on health workers worldwide, but post COVID, if such a thing is going to happen, there's also going to be a backlog to deal with.

So how do we re imagine this? 

Jessamy: It's difficult. I think it starts with investment, and it starts With honesty and with respect, and understanding that individuals who work in the health and care systems have their own lives and their own needs, and they have their own right to health.

We know that having this sort of paternalistic and traditional set of rules that puts the patient first at the sacrifice of everything else is a way of upholding Societies that have chronically underinvested in health professionals. So a start is to start investing in the number of health professionals and having that depth in the workforce.

That means that there is some flexibility, which we haven't had, and which has decreased drastically, really, in the last sort of In the last years in relation to demand, we have more doctors We have more nurses but in relation to actual demand things are very stretched in most places 

Gavin: You've been looking into this topic for these interviews and for the Lancet, because obviously you handled the the review that's coming through in this week's issue.

Was there an aspect of it that kind of most struck you? What do you think will stay with you from this topic? 

Jessamy: I think there are so many aspects, and obviously I, I think it's quite personal because we all have friends and colleagues and we've had personal experiences of working in these systems that can be very bad for people's mental health and very bad for people's lives.

I think, the suicide physician rate and the unexpected increased risk of females is particularly concerning. And taking a sort of gendered lens to that, the expectations that we have. of being able to do this incredibly complex and difficult job. This is not just physicians, but nurses, physiotherapists, occupational health, any health and care professional, people who are caring on a day to day basis, and then having the emotional labor and unpaid labor of home life and families.

is an enormous struggle, and one which we don't really recognize. Just the, the depletion on an emotional front of caring and looking after people all day, even at home and at work.

Gavin: Thanks so much for listening to this episode of The Lancet Voice. As ever, you can subscribe wherever you usually get your podcasts just by searching for The Lancet Voice. And we really look forward to seeing you again next time.