I didn’t think it could (would) happen to me

I’m sure like many readers of this issue of CUAJ, it’s difficult for me to imagine at this juncture of life a more gratifying career than urology. That said, since that first day in medical school, we have all had to struggle with that equipoise created by the fact that the job also comes with its significant stresses and unique challenges. In the recent past, I would venture to say few of us would publically voice our subliminal understanding that our complex work environment (and particularly in Canada the pernicious moral injury brought on by the imposed limits on patient care delivery) will eventually take a toll on our health and well-being. Recent headlines have finally shifted this conversation.

The Canadian Medical Association (CMA) has recently acknowledged that physician health and wellness is a growing concern within the profession and that we are at higher risk of personal and professional dissatisfaction, burnout, and depression. A recently published national survey reports that more than one in four physicians reported elevated levels of burnout and one in three screened positive for depression.¹ Urology is no exception.² However, it often seems that the conversations around nature, extent, and causes are nebulous (let alone offer any tangible solutions to enhance wellness and resilience). This is what seriously struck a chord when our Associate Editor, Dr. Marty Koyle, forwarded a letter describing some of his own experiences. With his consent and your indulgence, we felt that publishing parts of his brave, honest, and instructive story was timely and, perhaps, a call-to-arms for our extended urological community.

–Rob Siemens

Almost a year ago, I read with interest the article by Franc-Guimond et al in CUAJ entitled, “Urologist burnout: Frequency, causes, and potential solutions to an unspoken entity.”³ The last person in the world I thought it would affect was me. I was always mentally “up” and excited about my career, innovation, and promoting change. In fact, I had always said to my kids and those that I mentored that if your career only becomes a job and a means to an end, it is time to reassess or even quit what you are doing. What changes a year can bring!

I finished medical school in Canada in 1976 and left immediately for the U.S. to complete my training, and ultimately practice in three academic locations: UCLA, University of Colorado, and University of Washington. I was amazed at how well I was prepared for residency by my Canadian medical school training. Throughout my time in the U.S., I was always very supportive of the Canadian healthcare system and universal access. That being said, throughout my American career I was always satisfied with the superb personal care I was able to provide my patients and the fact that I felt valued by them and by my institutions. I personally knew virtually every referring doctor with whom I shared patients and the camaraderie within each institution among all specialties was vibrant. Sure, there were malcontents and naysayers, disharmony and dysfunction in some groups, but overall the majority of individuals who worked in those institutions seemed to be content.

Over a 10-year period, I suffered through significant family and physical challenges, and undoubtedly some of the turmoil in my life and career led to my recruitment back to Toronto and SickKids in 2011. With time, I realized the universal, single-payer system that I had been so proud of had stagnated. Moreover, it had become an entitlement system where, it seemed to me, the patients had no skin in the game. There were plenty of “no-shows” or “come when I wants” to clinics, which ran as impersonal assembly lines with varrying degrees of support staff. Surprisingly given our long surgical waiting lists, there was an overabundance of NPO violations causing cancellations and/or delays. I was aghast with the amount of paperwork and disorganization, and the amount of duplication and repetitive clerical tasks that fell on the physician’s shoulders.

A clearly evident comparison to the U.S. was the impersonal aspect of care, as well as the hospital and university culture of distinct and often competing silos, with lots of middle management and ever-changing strategic plans, often reacting to the provincial healthcare budget. The sense of team was lacking and the omnipresent potential for error weighed heavily. Despite a less litigious society in Canada, there seemed to be a more inherent internal practice of finger-pointing and blame. Furthermore, we work in an era of disruptive technologies and our work-a-day routine seems to be constantly impacted by yet another “efficiency” advance. Despite this confessional, I am a huge advocate of electronic health records when used properly (although I wasn’t when first forced upon us in Denver) and the addition of EPIC to our hospital will eventually be valuable. It’s key to try and shift from being an electronic health record “hater” to a “power-user” in order to take advantage of its potential.

Physicians are under daily stress to make critical decisions and perform with near perfection on behalf of our patients, all in a bubble of an imperfect and constantly changing system. The price we pay for this privilege is variable and highly dependent on each individual and the unique circumstances in which he/she works. Many of us are under constant scrutiny by the public, press, and social media. The recent CMA survey on physician health and wellness suggested that rates of burnout and depression are higher among our residents and more prevalent among female doctors than their male counterparts.¹ The recent American Urological Association survey suggested that of the nearly 40% of urologists that met the criteria for burnout, being a busy practitioner in a subspecialty area other than pediatric or oncology was a risk factor.²

As someone who enjoyed diversity of work and the responsibilities of medical leadership, I would have thought I was immune to “burnout.” Whether a culmination of moving, traumas in my life — both mental and physical — or disappointment with the healthcare that I am providing in Canada, I have changed. This manifests as a frequent sense of cynicism and criticism of the system that I work in, and a feeling that successes are not rewarded and only failure leads to a response. My sense of community seems to be diminished. Worse is a feeling of inadequacy to change my practice environment.

By writing this piece and publishing in CUAJ for my Canadian colleagues to peruse, I only hope it might lead to some reflection and might help in the national conversation around this clear and imminent threat. In retrospect, I wish I had the insight to identify these “symptoms” in myself and others, as well as some expertise to be able to advise those around me as to some strategies to prevent or deal with burnout. I am at the end of my career and am so fortunate to realize that I must address these issues, not ignore them. I have sought out professional advice and pursued wellness and mindfulness training. I would highly advise you seek out and identify these local resources to be prepared if, or likely when, it happens to a member of your team. Consider taking some of the information and policies from the CMA and Mayo Clinic websites to the physician leadership in your respective organizations and advocate for ongoing dialogue.^4,5

I commend Dr. Franc-Guimond and colleagues, and the CUA, for realizing that a strong, national organization can be supportive and advocate on behalf of its members.