This article originally appeared in the November/December 2020 issue of the Ontario Medical Review magazine.
by Stuart Foxman
In the midst of COVID-19, it’s time to expand the meaning of personal protective equipment (PPE), said Dr. Molyn Leszcz, a professor in the Department of Psychiatry at the University of Toronto. He adds that PPE should really stand for personal and psychological protective equipment, an alternative definition the university group created.
Speaking at the 2020 Physician Health Program (PHP) Day, a virtual OMA conference held October 28, Dr. Leszcz said that doctors are experiencing enormous distress during the pandemic. Consider the overwhelming demands in health care and then add worries about your patients, family, and personal safety and risk as the virus spreads.
There’s also the psychological toll of watching people die without family around. Plus a series of ethical dilemmas around a limitation in resources, and a powerlessness to provide care as desired in some cases. Doctors also encounter moral distress regarding an inability to always act according to one’s principles and values. On top of all that, factor in personal economic worry. That’s a long and burdensome list. “We’re in a crisis,” said Dr. Leszcz. “Any crisis is a mix of danger and opportunity”.
That was front and centre at PHP Day, the annual conference provides updates regarding the OMA’s Physician Health Program, with curated speakers. The audience includes those who provide care to OMA members (treating physicians, therapists, coaches and more), and other stakeholders. The event drew 170 registrants from across the province.
The PHP offers confidential support and a variety of services for medical students, residents and physicians in Ontario. These individuals may be struggling with stress, distress, substance use and mental health concerns, as well as with other issues that have a personal and professional impact. This year marks the 25th anniversary of the PHP.
Dr. Joy Albuquerque, PHP’s medical director, told participants that the Physician Health Program, in essence, is an occupational health service for the medical profession in Ontario. She said the goals of PHP are to transform physician health and wellness – at an individual, organizational and system level – and to be responsive to doctors in need. The work is highly collaborative. It could not be achieved without the support of stakeholders and the many clinicians who provide superb care to OMA members.
The PHP’s mission has four pillars:
Those pillars are the key drivers in everything PHP does, said Dr. Albuquerque. This is a particularly challenging time, as doctors and the health-care systems are being severely tested.
Talk of the pandemic’s impact and how to respond was the focus of Dr. Leszcz’s keynote talk, titled “Physicians and Emotional Wellness: COVID and Beyond.” He called the pandemic a “modal traumatic stressor on doctors.” When events like this happen, you lose some reflective capacity – you’re just not thinking in a complete way. What must happen? Self-care and mutual aid, for one. We need to take the opportunity to tend to our ourselves, our colleagues and our places of practice, said Dr. Leszcz.
He discussed emotion-focused and problem-focused coping. Proper sleep, diet, relaxation, exercise, mindfulness and social supports are all helpful. And when any of these is running short, Dr. Leszcz said we need to return to meaning- focused coping: why we do our work. So think about the vision and moral purpose, and the honour and dignity of the profession.
Dr. Leszcz identified five big needs for doctors during COVID-19: hear me, protect me, prepare me, support me, care for me.1 Within organizations, human capital is the chief resource. It requires safeguards as much as any other resource. “Physicians who work in organizations need to have confidence in their leadership,” said Dr. Leszcz. He said the hallmarks of effective leadership are being seen as competent, benevolent and operating with integrity. Leaders must be mindful, with every decision they make, about the impact on their people.
That demands a demonstration of what Dr. Leszcz called “organizational justice” – a sense that people are treated fairly. He said the best organizations are also marked by relationship justice and decisional justice, i.e., people understand and respect the process. “At the heart of everything we do, we should be promoting connection,” Dr. Leszcz said.
That’s another safeguard. Organizations must make every practical effort to avoid reasonably foreseeable injuries to the mental health of their people. A supportive and healthy culture is essential. “Burnout is physician vulnerability being met by an unhealthy culture,” said Dr. Leszcz. And it is leadership that sets the tone. “Culture eats strategy for breakfast every day,” he said.
Dr. Leszcz highlighted compassion fatigue and burnout, which is marked by exhaustion, a sense of futility and depersonalization. Doctors’ burnout is shaped in large measure by organizational forces. It’s a systemic issue by and large, building atop doctors’ perfectionism, doubt, guilt and sense of responsibility. A lack of connection, lack of competence and lack of personal control are all threats.
As Dr. Leszcz reported, there’s good evidence that the culture of the organization has a significant impact on clinical outcomes. Having a healthy workplace, one where people are engaged, measurably improves patient care. So if you want high-quality care, one way to achieve it is to treat your staff well.
Anticipate that system pressures will generate significant conflict, which can become more destructive and corrosive, Dr. Leszcz said. To counter that, in part, you need clear, consistent, timely and relevant communication. Education around stress and traumatic symptoms is also enormously helpful. Buddying up can make a difference too, so you can share what’s going on, vent emotions, check in regularly, or lend a helping hand to each other.
Groups are enormously important, whether formal and informal. “They normalize vulnerability,” said Dr. Leszcz. If you’re running one, emphasize safety, calming, a sense of self/team efficacy, connectedness and hope. There has been some increased attention to physician well-being and mental health during COVID-19. But the issues that many doctors grapple with are enduring concerns, which is why the PHP always needs to be in a position to respond effectively.
During her update, Dr. Albuquerque ran through the Physician Health Program’s four core services: intake, case management, the PHP assessment service, and education and prevention. New this year is a wellness support line (a CMA-funded program), a confidential service piloted during COVID-19. It offers covered supports for physicians and their families at 1-800-851-6606. PHP services can also be accessed by calling the same number, or by email at email@example.com.
Dr. Albuquerque described the newly named Physician Support, Advocacy and Accountability Programs (PSAAP) as a type of case management. It’s a way for PHP to go along somebody’s journey. PSAAP assists physicians (including residents and medical students) with mental health, substance use or professionalism needs. This was formerly known as the monitoring program. But the negative connotations of the term resonated poorly with participants, and did not reflect the collaborative nature of the program, said Dr. Albuquerque.
Instead, she described PSAAP as an occupational health service that helps doctors return to training or practice safely. It supports them as they work, and helps to pick up on early signs of a potential relapse or recurrence of health or behavioural issues. The PHP assessment service is for individuals who are referred by a third party, as a result of raised concerns, for an evaluation of their health or fitness to train/practice.
Lastly, education and prevention encompass presentations or workshops around a wide range of themes, from information about physician health, to resilience and stress management, to issues specific to workplace wellness, and more. Dr. Albuquerque states that the Physician Health Program aspires to be a hub for the profession, including an organization wellness network, an academic network, and a caduceus facilitators’ network (a health care professionals’ support group for those in recovery from substance-use disorders).
Coming soon is a treatment providers network for those who treat and care for physicians and students. Awareness, connection and support are cornerstones of cultural change, and challenge stigma and discrimination. If PHP services are about saving lives and enabling careers, that ultimately benefits everyone, and impacts our workplaces and the bottom line – our patients.
Dr. Michael Kaufmann, Medical Director Emeritus, PHP, echoed that sentiment when speaking at the PHP Day conference during a 25th anniversary overview of the program. For every doctor PHP helps put back on their feet, think of all the people they’re serving. “That magnifying effect is so gratifying,” he said. “To be part of a profession where we look after ourselves fills me with a deep sense of pride,” said Dr. Kaufmann.
PHP Day explored another COVID-19-related issue: how do you effectively maintain a toxicology program in this time for doctors with a substance-use disorder? Dr. Lisa Lefebvre, Associate Medical Director, PHP, talked about the challenges of continuing biological testing, a component of PSAAP for those with substance-use problems. During COVID-19, lab collection sites had limited their hours, and some closed. Participants were concerned about contracting and transmitting COVID-19 when providing tests. In light of COVID-19, toxicology protocols were modified. The underlying principle was to balance public health concerns with the participants’ accountability as monitored safety-sensitive workers.
Dr. Jon Novick, Associate Medical Director, PHP, noted that some said the changes to the toxicology program had the potential to destabilize their recovery. Others reported a sense of appreciation that PHP cared about their risk of contracting COVID-19 when providing a test. Dr. Novick said there was conscious appreciation from many participants for being in a strong recovery program as a protection, in light of the isolating experience of COVID-19.
Physician Health Program clinical coordinators commented that the changes to toxicology testing created more opportunity for them to schedule more check-ins than usual. This fostered growth in the relationship, increasing potential for advocacy and support. COVID-19 was also an opportunity for innovation, as evidenced by an expansion of a remote breathalyzer pilot program to any interested participants. That allowed them to continue with less frequent urine testing, which reduced their exposure to others at lab collection sites. The pandemic also opened discussion in the PHP community across North America, regarding innovative ways to reliably collect point-of-care toxicology tests. Out of necessity, the pandemic showcased collaborative and nimble problem-solving between the PHP team and program participants. Going forward, this can serve as a model for improved service delivery.
When it comes to our overall well-being, how do we survive COVID-19? Be kind to yourself. That was the advice given by Dr. Mara Goldstein, associate medical director, PHP, in one of the breakout groups. We haven’t experienced a pandemic before, she said. Things are different. So give yourself a break. “Nothing good happens in health care without a robust and supported cadre of health care providers,” Dr. Leszcz said earlier in the day.
His poignant message applies not just to those who care for or support other physicians, but to every doctor. Get a clear understanding of the many ways to cope, so you can draw on that explicitly as needed. Ordinary practice (and life) can be full of stresses, and we can find ourselves struggling at the best of times. And these are not the best of times. Still, “Let’s not waste this crisis,” said Dr. Leszcz. With the right strategies and supports, he said, we can move to a place of resilience, anti-fragility and growth.
The Physician Health Program provides confidential support for individuals who are struggling with substance use and mental health concerns, as well as with other behaviours that have a personal and professional impact. The PHP also offers support and education to physician leaders, hospitals, and other worksites; as well as to anyone else who is concerned about a loved one or colleague. Our services are aimed at supporting a culture of medicine that values prevention, early identification and intervention of health concerns, that supports both the health professional, their loved ones, and the workplace. Learn more about PHP.
Stuart Foxman is a Toronto-based writer.
In a letter to OMA Chief Executive Officer Allan O’Dette, CMA President Dr. E. Ann Collins recognized the OMA’s Physician Health Program for 25 years of service to Ontario physicians and medical learners.
Dr. Collins thanked the program’s leadership and staff – past and present – for their dedication to the health and wellness of the thousands served by the PHP program, for the lives saved, and acknowledged the OMA for its sustained investment in the health and wellness of Ontario’s physicians and medical learners.
“As an early pioneer of physician health and wellness in Canada we understand your program to be among the first of its kind in our country – starting as a volunteer helpline, and quickly evolving into a dedicated, robust service. We also share in your guiding belief that physician health matters and that education, early intervention and treatment are critical to sustaining a healthy profession. In these challenging and uncertain times, we feel it is now more important than ever to support the health and wellness of physicians and medical learners, and this important milestone gives us occasion to acknowledge the critical service PHPs provide to our profession in Canada. The OMA PHP is a shining example of physicians supporting physicians – a pillar of a supportive training and practice culture. This is something we should all be proud of.”
– Dr. E. Ann Collins