Diana Toubassi is an Assistant Professor in the University of Toronto Department of Family & Community Medicine.
As my city braced for our local COVID-19 onslaught, I had the strange experience of facilitating the final session of this academic year’s undergraduate reflective curriculum. As part of this curriculum, my assigned group of medical students and I had been meeting regularly for the better part of two years, coming together to reflect and commiserate on their most poignant and challenging training experiences. Over that time, I had been repeatedly impressed by the students’ insight and candor, and grew to anticipate our often-transformative discussions.
That last afternoon clearly felt different to us all. In adherence to novel social distancing requirements, we congregated virtually, making use of one of a number of increasingly popular online meeting platforms. Instead of crowding around a small table, elbow-to-elbow, in a sunny room on campus, each of us huddled in solitude at our personal computer screen, gazing at familiar faces against unfamiliar backdrops – kitchens, bedrooms, a backyard. It was awkward and bizarre, and I was struck by how deflated the students seem. Having completed their required clinical rotations and examinations, they are on the cusp of graduation and the beginning of residency.
None of them could have remotely conceived this peculiar, suspended reality.
The students shared guilt at being on the sidelines, at having potentially useful skills that remain regrettably unused. They shared grief also, at the unexpected, anticlimactic conclusion to their undergraduate training – then guilt again, at having the audacity to note their own losses in the midst of a global health crisis. I struggled to know what to say to them, their experiences both distressing and justified.
“You’re grieving what you’ve lost, and filled with anxiety about the future,” I offered. “I am, too. This is a time of remarkable uncertainty and challenge, not just for our profession, but for the world.” I looked at their expectant faces. “But – ” I continued, “it has never felt more meaningful to me to be a physician.”
Our group had previously discussed the well-established statistics on mental health issues among physicians. We had lamented the distressing prevalence of burnout, depression and suicide in our profession, and speculated at length about the contributory causes.
Despite being relative newcomers to the clinical world, my students had identified quite quickly the unrelenting stresses and hassles that hound physicians across specialties and practice settings. They had perceived the ever-expanding size and reach of bureaucracy in its various forms, the subjugation of humanity and clinical judgement to the electronic medical record, and the specter of litigation that drives over-testing and over-treatment. They had spontaneously recognized the enormous clerical burden foisted onto physicians, as well as the unnecessarily complex workflows and unwieldy team structures that plague many health care environments.
In an attempt to normalize the conversation about physician well-being (or the lack thereof), I had earlier disclosed to my assigned students my own challenges with burnout. I had been honest in describing the fact that as I approached “mid-career,” I had found myself feeling increasingly frustrated, weary and resentful. Patient complexity seemed to continually and inexorably increase over time, the pace of the workday was intolerable and merciless, and the work itself, unending. In the darker hours of my more trying days, I had wondered about the value of the work I was doing.
How suddenly the world has changed.
Physicians now hear a call, on a scale more massive than any of us have ever before experienced, and we appear to give an instantaneous, near-instinctive collective answer. Each of us rises to the challenge, bringing to the effort whatever we can.
The work itself is difficult, each day uncertain and overwhelming. Our clinical duties are themselves exhausting – long hours undertaken in restrictive personal equipment that limits our ability to rest, drink or eat, and that conceals our faces, alienating us from our own colleagues. We worry for our patients as they battle a new disease against which we have few effective weapons. We worry for ourselves, especially in light of substantial concerns about PPE supply. We worry for our loved ones, potentially vulnerable to the infection we would carry home to them; it feels cruel that they could pay a considerable price for the careers we have chosen. Many of us struggle with the dearth of care for children who are now home from school, when community members are understandably afraid to cross the thresholds into our homes.
Despite all this, there is a new feeling to the practice of medicine, an intuition, a remembering of the higher call to service.
As the usual distinctions between physicians dissolve, hierarchies and divisiveness yield to kindness and mutual support. There is willing, even enthusiastic, self-sacrifice. Leadership – true leadership – emerges, often from unexpected places. Hospital and government bureaucracy, typically beset by inertia, is mobilized surprisingly quickly and with minimal partisanship. Pettiness surrenders to camaraderie and empathy. The usual drudgery and struggle are supplanted by purpose and meaning.
I realized, as I reflect back on my own struggle to define the meaningfulness and utility of my work, that my ennui had not been a result merely of physical and emotional fatigue (although both were certainly considerable). Rather, I had become consumed by disillusionment with the nature of so-called “modern medicine”. The conditions we currently face, although remarkable and arduous, have recalibrated my perspective, revealing to me what is possible for our profession.
I looked at the medical students I was charged with teaching. They looked young and hopeful and full of promise. I bade them farewell a final time.
“Despite all the challenges that lie in wait,” I told them, “you are so truly fortunate to be entering this profession.”
And I could not have meant it more.