Christy Stephenson is a family physician in Kingston, Ontario.
As the COVID-19 pandemic marches on, calls for physicians and residents in Canada to safeguard their wellness and promote resilience by “maintaining balance” are ongoing. Recently, we have mourned the tragic loss of a colleague in Quebec. In a study published March 3rd 2020, Ferguson and colleagues found the prevalence of burnout among resident physicians in Alberta to be as high as 69%. And the Canadian Association of Emergency Physicians reported that, out of their respondents, 14% had contemplated suicide within their careers, and 6% had thought of it within the past year. So calls for physicians’ mental health to be protected are important. However, despite growing recognition of the problem, and improvements in faculties’ wellness curriculums, achieving the elusive state of balance and wellness is impossible for many learners and practicing physicians.
Balance, as I understood it in my former life as a gymnastics coach, is achieved when the body of mass is centered over the base of support. When the center of mass tips beyond the edges of this base, you fall. There are several ways to correct this: contain your mass by pulling everything in tight; extend your limbs in opposite directions to create complementary forces; or, most simply, enlarge the base of support.
I can imagine a career as a physician as the center of mass, while one’s life outside of medicine serves as the base of support. As the career expands into longer hours, more extensive clinical and administrative demands, larger practices, and higher patient expectations, the base often shrinks at the same rate. Balance becomes near impossible to achieve and a fall is unavoidable.
Wellness, and the balance required to achieve it, is so highly regarded among physicians that the governing bodies have attempted to mandate it. The Royal College of Physicians and Surgeons of Canada incorporates it into its “Professional” domain of the CanMEDS roles. These are the core competencies that a physician must have in order to effectively meet the health care needs of the people they serve, and includes “a responsibility to self in order to serve others” and “resilience for sustainable practice”. The relationship between self care and patient care needs little explanation – it is obvious that a physician who has not slept or eaten is likely to pose a risk to patients or, at very least, perform sub-optimally. However, medicine is a field where training and service requirements often preclude adequate sleep and meal time, let alone time to exercise, practice any form of spirituality or nurture relationships outside of medicine. While it sounds progressive, effectively mandating wellness through the CanMEDS roles may be entirely counterproductive. It forces entanglement of those activities that a physician does for themselves with the endless expectations for professionalism and patient care, which essentially pulls from the base of support to add to the toppling load above.
Though there are outliers, there is a culture among physicians and, I would argue, an expectation from the general public, that being a physician isn’t “just a job”. However clichéd, the idea of a “calling” is widespread. For some it may be true. For others, it may be a truth they’ve created and lived in to survive the rigors of applying to and completing medical education, matching to a certain specialty, and truly caring for patients under a system that fails to recognize what this entails. If it were “just a job”, the work would end at handover, and the mental space dedicated to the needs of patients could be reassigned to other things, other people, other passions. Meeting the standard of care would always suffice. However, we know this isn’t the case and that, if it were, patients and families would suffer. Physicians would suffer too, because it is often the “superfluous” moments of humanity and care which lend meaning and fulfillment to this work. This idea of a calling justifies, right or wrong, the insidious spread of the career into the further reaches of one’s life.
While focusing on personal wellness and cultivating those aspects of oneself that exist outside of medicine is sometimes encouraged, the idea is fundamentally discordant with the way we work, learn, and are encouraged to identify with this “calling”. As a resident, I struggled with this paradox endlessly and found myself hesitant to share my interests and pursuits outside of medicine with more senior physicians and colleagues. Often, admitting to a life outside of medicine – time spent developing or maintaining my base of support – felt like a loaded and potentially dangerous proposition. I feared revealing a selfish desire to disconnect from the “calling” or outing myself as lazy, unmotivated, or unprofessional. Now, as a staff, with more autonomy over my schedule than I have ever had, the same feeling persists, and I now see it reflected in the residents with whom I work.
In the middle of COVID-19’s second wave, we continue to work longer hours, with fewer resources, and more constant worry. This, at a time when the usual opportunities for exercise, social connection, and disconnection from occupational stress are greatly restricted. For learners, the light at the end of the tunnel may not be as bright, as licensing exams, job prospects, and even the practice of medicine itself are cloaked in a fog of uncertainty. “Future orientation”, I can only imagine, is at an all time low, because the future is disorienting, at best. Limbs flailing, we are balancing on the tip of a finger.
It is impossible to avoid discussion of COVID-19, even outside of the workplace. That said, from the beginning of the pandemic, I have found the widespread understanding among physicians that “this will be hard” both heartening and inspiring. There has been no “admitting” we are struggling even as we are all struggling. We are leaning on each other, and offering ourselves to be leaned upon knowing it will get harder but we need to make it out the other side.
The magical thing about balance is that, when one balancing object leans on another, the base becomes more than the sum of its parts, encompassing the space between them to create stability greater than either could have achieved alone.
“Balance”, at least static balance, likely isn’t achievable right now – and I argue it never was. It may be the perfect time to abolish the fallacy of “balance” in medicine, and take the opportunity to explore and genuinely encourage those activities, still available to us within this time of uncertainty and unending workload, which support wellness. Take breaks, breathe, drink water, go outside, eat lunch, laugh and cry together, relish in moments of humanity, and be extra kind to each other. Consider the harm done by entangling wellness with professionalism, and start changing the culture of medicine to support true resilience.
Broaden and nourish the base of support. Be expecting and accepting of a need for continuous adjustments and occasional, inevitable falls. Know whose hand is there to help you get back up – and offer that hand when you can.