Physicians are at a crisis point. Even before COVID-19, we saw an alarming increase in the number of doctors experiencing burnout, loss of connection, or even moral exhaustion with their work. The pandemic has only exacerbated this frustration and fatigue. CPSO recognizes the extraordinary pressures inherent in the practice of medicine, as well as the threat physician burnout poses to patient care. The pandemic has caused chaos and misery, but it also began normalizing conversations about physician mental health. As the regulator, we need to be a part of this crucial conversation. We hope this series of articles conveys our support for physicians and encourages those who need help to seek it out. Also in this series: Reaching Out for Help and Pandemic and Mental Health.

The medical culture told Dr. Jillian Horton that to succeed, she needed to detach and push through. She explains the extraordinary toll that took on her.

On her drive into work one morning, Dr. Jillian Horton saw a pedestrian collapse at a busy intersection. She moved swiftly, keeping him safe from passing cars while she resuscitated him. An ambulance was called and the man was taken to hospital. Once fully recovered from his heart attack, the patient and his family expressed their deep appreciation to Dr. Horton for her quick actions.

But the Winnipeg doctor was uneasy with their gratitude. Instead, her mind was occupied with all that she failed to do. Why didn’t she send someone across the street to get a defibrillator from the synagogue? Why didn’t she check the man’s wrist for a Medical Alert bracelet? And how irresponsible not to ensure the CPR mask she usually carried in her car was put back before she left for work that morning.

Most people would be puzzled by Dr. Horton’s complex response to what would universally be considered a heroic moment, but those people, she says, are not likely physicians. “It may not have been the usual response, but physicians would understand it,” she said in a recent interview with Dialogue. “It’s that chronic, instinctive, unrelenting performance appraisal that we all do. It’s the critic that most of us already come to medicine with, but then solidifies because year after year after year we are constantly tormented with, ‘What did you do wrong? What could you have done better?’”

And, besides, as Dr. Horton described in her memoir, “We Are All Perfectly Fine,” there is very little that is normal about the pressures physicians experience. “In the process of becoming a doctor, normal dissolves like white powder in warm liquid. It’s not normal to go without sleep. It’s not normal to watch people die, then go drink a cup of coffee and talk about your plans for the weekend. It’s not normal to be blamed for not knowing what you couldn’t possibly know,” she wrote.

In her youth, Dr. Horton had considered becoming a writer, but medicine ultimately had a stronger pull. “If medicine is a calling, my sister, Wendy, is the reason I answered the call,” she said in a recent podcast.

Wendy, 12 years older, was diagnosed with a deadly brain tumour at the age of six. After the surgery, Wendy developed post-operative meningitis. When her parents met with the neurosurgeon to better understand their daughter’s prognosis, he shoved Wendy’s scans into the lightbox and yelled, “Can’t you people get it through your heads? The problem is there is no brain left!”

The words seared the Hortons, but it was not the only time the medical profession left the family feeling abandoned. Growing up as Wendy’s sister, Dr. Horton says she came to understand ableism before it even had a name.

“I think about the unimaginable number of medical appointments that I, over the years, attended with my sister and my parents,” she said. "And I watched how badly some physicians treated her as a vulnerable and disabled person, and those experiences affected me profoundly. All the compassion that I show in my interactions with patients traces its way back to Wendy because I so deeply understand how kindness would have made the world of difference to my family — just to have someone recognize that she was much more than just an unfortunate girl with a brain tumour.”

Her family’s experience set her on a path to enter medicine, determined to reform the profession from within. And kindness would be her North Star. As a young resident, she would sit with scared patients long after other clinicians had left the room. She did so because she understood that moments of kindness in clinical care can have a lasting impact on patients’ well-being.

“A lot of us are taught that emotional attunement is fluff. It’s useless and that your goal is to be fast and efficient. And what I always like to remind people is that efficiency is a value judgment. The time that you invest in that encounter, answering their questions and connecting with them, is as important to the assessment as checking the blood pressure, getting the blood sugar,” she said.

Dr. Horton, an internal medicine physician, says the literature is clear — patients who experience a compassionate physician have better outcomes. “If you take those few extra minutes to establish trust, then they are going to listen to your advice, and they will take the medication or have the procedure you recommend. For too long, there has been a tendency in medicine for people to just rest on the authority of the white coat. But that’s no longer accepted by the public and that shouldn't be acceptable to us.”

But as kind as she was to patients, she was cold and indifferent to her own needs. To adapt and survive within the health care system, she felt she needed to be. As she wrote in her book, “We split from our bodies so we can learn to be doctors. Isn’t that ironic? We deal with corporeal failures, but we think we can program bodies, our bodies, to run without sleep, or food, or hydration. We learn to work through utter exhaustion. We dismantle the safety valves evolution built to keep us from doing anything important or dangerous on too little sleep.”

Medical culture told her that to become a successful doctor, she had to detach and push through. Her book describes the experience of a fellow resident who cried after visiting the room of a young mother with a catastrophic brain bleed. The staff physician admonished the resident for her response. “This is an emotion-free zone,” he told her.

It is a declaration that doesn’t square with reality. “Physicians have the highest rate of suicide of any profession. That doesn’t sound like we are working in an emotion-free zone, does it? That fact reflects that we are working in zones of deep suffering,” she said.

Her own suffering manifested in total indifference to herself. “There was a sense of disconnect with the rest of my life outside of work,” said Dr. Horton, who is the married mother of three young boys. “I could not focus. I could not be present. I was a husk. I would get home and just feel like there was nothing left — absolutely nothing. It was like I had prepared a beautiful dinner for my patients and then I would come home with these burnt-out garbage scraps to feed to my family.”

She did not recognize her unhappiness as burnout at the time. “Often, when we think of physician burnout, we’re looking for those other things — being a jerk at work, yelling at patients, making big clinical mistakes. By the time those kinds of signs are visible, it is very late stage. Most of us instead conceal our unhappiness because if you really value your colleagues, if you're highly relational, you'll hang on to those things until the very end. And in the meantime, who ends up getting the short end of the stick? Your family, the ones who love you the most. Because you know they won’t complain about you. They will forgive you,” she said.

Understanding that she needed to find a way back into her life, she accepted — reluctantly — an invitation to attend a Zen retreat in the woods of upstate New York created especially for physicians. There, as she listened to other physicians share their own stories — their grief about the patients that still haunt them, their fear of falling short of the expectations that define them — Dr. Horton began to recognize herself in their narratives. Slowly, over the course of the next five days, she began to realize her pain was not unique to her, but the result of a larger system failure, one that forced physicians to suppress their most agonizing emotions at all costs, even if that meant choking on their own misery.

She also developed some empathy for the physicians who had treated her family so coldly. Maybe, she says, they were not necessarily bad people, but just products of a toxic system.

“Self-compassion was completely absent from my life until a relatively short time ago, and that lack of self-compassion just contributes to you feeling chronically terrible and that nothing will ever be good enough,” she said. “And maybe if you talk to yourself like that for 20 years, you start to forget your other words. I don’t excuse it. I still find it repugnant, but clearly many physicians have maladapted to a medical culture that has brought them to an emotional state where they're so numb and cut off from everything around them that they no longer recognize how their behaviour impacts other people.”

The crushing anxiety and call for help has only become more urgent since the rise of COVID-19. “I really don't think we can overemphasize how fragile physicians are right now. Physicians are afraid. Physicians are struggling. And physicians, in many cases, are questioning their career choice in ways that are qualitatively different than before,” said Dr. Horton.

The crisis of burnout — exacerbated by COVID-19 — led Dr. Horton to amplify her efforts to support her peers. She interviews physician leaders in “Conversations with Jillian” for the Royal College of Physicians and Surgeons of Canada and hosts a series called “Arts, Medicine, Life” at the National Arts Centre. She also has taken the conversation about burnout to the opinion pages of the Globe and Mail, Toronto Star, Macleans, Los Angeles Time and CNN. Often, she will use those opportunities to take political leaders to task for abdicating their responsibilities to patients and health care professionals.

Dr. Horton is also the inaugural director of a physician and wellness program at the University of Manitoba. To honour her commitment to compassion in medical education, Dr. Horton was presented with the Gold Humanism Award by the Association of Faculties of Medicine of Canada.

As devastating as COVID-19 continues to be, Dr. Horton believes it has been invaluable in creating conversations around physician mental health. She is optimistic that the growing awareness of burnout will be reflected in how medical schools are run and how hospitals are administered. But institutional and system change happens very slowly, and she urges individuals to focus on what they can control — their own response to stress. She likes to quote Dr. Rollo May, the existential psychologist: “Human freedom involves our capacity to pause between the stimulus and response and, in that pause, to choose the one response toward which we wish to throw our weight.”

Dr. Horton has returned to the Zen retreat several times. The wisdom gleaned during those visits, she says, allowed her to practise with a mindfulness and clarity that she has never enjoyed before. “Instead of always trying to mash uncertainty to a pulp, I simply say to myself, ‘This is just an unavoidable and intrinsic aspect of the quality of being human.’ And when we learn to live shoulder to shoulder with that uncertainty and not treat it like a hated enemy, everything changes, including the assessment of our performance.”