"Silence is not golden. Silence is permission." -- David Maxfield, on bullying in the medical workplace

Disruptive behaviour is not a normal part of medical culture.  That means that is it not common or normal for surgeons to throw instruments, psychiatrists to sleep with their patients, or internists to use tantrums to get their own way; the vast majority of physicians practice in a highly professional manner.  However, the profession and the health care system struggle - really struggle - to intervene and remediate such behaviour when it occurs.  Thankfully, only 3-7% of physicians demonstrate behaviour that can be described as disruptive.  But the impact of that small number of physicians can be profoundly strong and long-lasting.

Why?  Many practice environments don't have useful and practical Codes of Conduct for physicians. Many health care professionals struggle to effectively hold a physician accountable for inappropriate behaviour.  Many remediation programs take time, dollars, and hard work.  Many physicians who demonstrate inappropriate workplace behaviour are stressed, burnout out, ill, or addicted.  And, sometimes, the physician is under tremendous strain from practicing in a toxic practice environment that suffers from poor leadership and management.  The issues are typically very complicated.

Forbes published an article on this very issue last week - and highlighted some of the VitalSmarts courses that I teach at uOttawa - Crucial Conversations and Crucial Confrontations/Accountability.  I have seen these courses help many physicians rapidly develop insight into their behaviours (and that of others) and apply evidence-based skills to difficult situations in highly effective ways. 

How has your practice or training environment prevented, intervened, and remediated disruptive behaviour?

Guest Blog: Dr. Gina Higgins - Yellow Belt, Rural Family Doc, Leader of Physician Health in NL

Dulce et decorum est…

“Doctor, you’re some hard to get in to see”.
“Doctor, I couldn’t get an appointment to see you for another week, so I figured I’d ask you here…” (in the grocery store, children’s birthday party, restaurant, karate class)
“Doctor, your patient has been calling in all day for this prescription refill. No, they haven’t made an appointment, and by the way they need it in the next 20 minutes before going out of town for a month”.
“Doctor, I know you’re running behind and need to pick up your sons but Ms M says her little boy has frothy pee and some swelling and needs to be seen. No, she says they can’t get to the walkin clinic and she hasn’t got childcare for the rest to be able to wait in ER”.
“Doctor, the office of the specialist you referred Mr R to called and said you need to fill out this stack of forms instead of the consult you already wrote. Yes, it requests the same information you already gave, but look; here they have special blanks for each bit of information. They say it helps triage patients and streamline their clinic…”
“Doctor, you’re turning an amazing shade of purple…”

This week, I told a patient she needed expedited investigations to rule out likely breast cancer. I delivered a baby whose heart rate had dipped into the 70’s, precipitating cutting an episiotomy to deliver quickly, then managing a moderate post-partum hemorrhage in the babe’s mom who had a retained piece of placenta. I did a biopsy on a young lady who possibly has scleroderma. I told a young man that the reason he and his partner could not conceive was that his sperm count was far too low and had no apparent reversible cause. I told a middle aged lady whose brother was on dialysis that she had the first signs of chronic renal failure. I had to discuss all these things, put investigation or management plans into place in collaboration with the patients, or in the case of the intra-partum scenario, I had to work fast to manage issues that could end up in a baby and/or its mother dying or being compromised for the rest of their lives.
It is only recently striking home that clinical stuff like this is the nicest, most relaxing part of my job. Hard on the heels of that thought is “Oh, my God” (or some iteration thereof). It is easier to tell a patient they have cancer than it is to hear day after day how hard it is for patients to make an appointment.
What demented logic has fostered this? “What rough beast, it’s hour come round at last, slouches towards Bethlehem to be born?” (Keats, The Second Coming). I, like most others, went into medicine to help others. It is often assumed that physicians hang out their shingles to make some serious cash, but when you take a closer look, if money played the leading role then choosing medicine is the most asinine decision a person could make. It would be like agreeing to simultaneously take on six sumo wrestlers so that one could get some exercise. Physicians have a hypertrophied sense of responsibility. No, not hypertrophied. More like responsibility on ‘roids. Pair this with the sense that we are only worth anything as people if we give everything we have to others, through medicine, and really we end up early-on queuing our own brainfuls of schoolyard bullies as sort of self-flagellation devices. Really, if you want a job done right, do it yourself. Who else could be as hard on ourselves as…well…ourselves? And what other motivation could be as effective as the internal rod and weal? For the perfectionistic, obsessive and vulnerable physician-prototype, there can be a comfort and relief in adopting this approach. Pre-emptive martyrdom takes away those scary senses of intolerance of existential uncertainty and dread of worthlessness and inferiority. Those nice little baskets full of self-actuation earned when we give of our extra time to help our patients make it all worthwhile. We don’t always fully realize that the value we ourselves place on these prize baskets increases based on what we (or our friends and families) must sacrifice to win them.
To be the eternal unfailing hero and to be human are incompatible. To strive for both while understanding and accepting limitations is admirable. To try to hold with utmost care, compassion, and competence the lives and health of others is the honor we assume day to day. To give of the self until the self is defined by the giving, to hold one’s own reflection up to the harsh light of day often enough to burn away any shadow of illusion, to continue to guiltily hold those illusions hostage as we try, again and again, to be everything to everyone; that is to be a physician. Medicine is easy. Co-existing with medicine is the hard part.
…pro patria mori.


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Guest Blogger Bio:

Dr. Gina Higgins  -  "I'm a 37 yo family doctor, in a full time group practice including obstetrics. In the past, I have worked at everything from critical care and hyperbaric nursing to shelf stocking at Walmart.  I work with the Newfoundland and Labrador Medical Association Physician Care Network, Faculty of Medicine of Memorial University as Student Affairs Director (Distributed Sites) and Master's student at the University of Western Ontario.  I have two lovely little boys, and a cornish rex cat.  I just got my yellow belt in karate and have a narrative published in a family medicine textbook."

The chipping away of a resident's resiliency

Residents have many lines of accountability.  First, their employer (and that may vary by time of day, building, and rotation) has high expectations of the volume and quality of patient care that they will provide.  Second, their program has high expectations for their training, education, and development of competencies.  Finally, their family has high expectations of whatever time is left over after meeting these other demands.  

I didn't mention the self. On purpose.  Most residents, particularly first year residents, rapidly sacrifice their personal life in hopes the sacrifice will be time limited and well worth the cost. 

So what is the price of meeting all of these demands? In a study of american family medicine residents it seems very high.

A group of family physicians published a study of 168 first year family practice residents in the USA, reporting that they all started their training in pretty good emotional and physical shape.  However, as the year progressed, 23% met criteria for depression, 14% met criteria for high emotional burnout, and 24% demonstrated relevant symptoms of depersonalization.  

Depersonalization also emerged as a relevant risk factor for use of medication for sleep, mood, and anxiety amongst residents, and this risk was higher if the resident was female.

And using alcohol to cope?  The higher the use of alcohol the more severe the levels of perceived stress, symptoms of burnout and feelings of depression.  So much for thinking a few extra mixer parties would take the edge off...

The authors recommended that restful sleep and exercise were associated with more positive well being in residents, so efforts looking at resident duty hours are important as are principles of promoting healthy weight, nutrition, and fitness amongst trainees.

How does your program help new residents stay well?  On July 1, 2014 Canada will welcome several thousand new first year residents.  Wouldn't it be great if we could help ensure 24% of them do not become depressed or depersonalized?

A worthwhile hop across the pond: the 2014 International Conference on Physician Health

Every two years, the international physician-health community gets together to share best practices, disseminate new knowledge, swap stories from the front line, and reconnect with friends and colleagues.

This year, the International Conference on Physician Health will be held in London, UK from September 15 - 17.  The theme is Milestones and Transitions - Maintaining the Balance and keynotes from Professor Dame Carol Black (talking about concepts of "good work" and "workplace wellbeing") and Professor Jim Lucey (sharing lessons learned from pilot Chesley Sullenberger's experience landing US Air 1549 in the Hudson River) will be excellent.

15 workshops and 15 research symposia will anchor the conference and participants will have ample opportunity to participate in networking sessions, mindfulness medication, qi gong, and walks/jogs around London city.

Canada has a longstanding tradition of co-hosting the conference and, in 2012, a sold-out (and overflowing!) ICPH was held in Montreal, Quebec.  A shared responsibility of the Canadian, British and American Medical associations, the conference is the world's largest gathering on the topic of physician health and wellness.

Will be a jolly good time, no doubt.

What really works to reduce the consequences of stress in physicians and medical students?

Thanks to a meta-analysis completed by colleagues at uToronto and Queen's we have some ideas:

- anxiety symptoms drop with cognitive, behavioural and mindfulness interventions

- burnout symptoms drop with psycho-education, interpersonal communication enhancement, and mindfulness meditation

Given that up to 46% of Canadian physicians struggle with symptoms of moderate to severe burnout, and that rates of anxiety are higher in medical professionals than the general public, these conclusions are important.

Indeed, studies like this help identify competencies that can be embedded in models of training and practice, such as the emerging CanMEDs 2015 framework (specifically, the Professional Role).

Mindfulness is a well-established practice that effectively reduces stress and prevents symptoms of burnout.  Training designed for medical professions can be found locally, in various parts of the country like Montreal, or further afield.

First Post

I love being a doctor.  

I help children, teenagers and families through some of their darkest times.  I learn from a diversity of intelligent and highly competent colleagues in medicine and other health professions.  I teach students, residents, and colleagues (and learn way more from them than they do from me).  And I have fun doing research, writing books, developing eLearning resources, coaching and all sorts of other stuff. 

Not a day goes by that I don't feel grateful.

I've also experienced and observed that being a doctor is hard.  Sometimes life inside medicine is so bizarre, so traumatic, and so intense that people outside of medicine simply can't understand.  The consequences of this are higher rates of depression, burnout, suicide and other forms of illness and impairment.  And doctors find it very difficult to access health care and many doctors find it hard to care for a colleague.  

With these things in mind, I became interested in the field of "physician health and wellness" - a small area of medicine that helps doctors care for themselves and each other.  Why?  Healthy doctors practice better medicine.

And that is a very good outcome.

This blog will focus on physician health and, from time to time, other aspects of health-professional health.  I'll share new knowledge from the literature, talk about unique projects and services, promote conferences and events, and - hopefully - generate a conversation with you.  

I'm looking forward to the adventure!