Book Reviews
Reviewed by J. Van Aerde, MD, PhD
Since last fall, many books have been published by Canadian physicians. We chose four to review in this issue: We Are All Perfectly Fine by Jillian Horton; Without Compassion There Is No Healthcare by Brian Hodges, Gail Paech, and Jocelyn Bennett; Hardwired by Robert Barrett and Louis Francescutti; and Stress in Medicine by Nina Ahuja.
We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing
Jillian Horton, MD
HarperCollins, 2021
Reviewed by J. Van Aerde, MD, PhD
In a journey of self-discovery, Horton explores her fatigue, disappointment, and misery in medicine and how her own mental models and painful experiences are as much at fault for her pain as “the system.” Horton loves medicine; she is grateful for the privilege of serving patients, relieving their suffering, and being present for them. The disappointment and misery are related to medicine as an institution — how it eats up its trainees and physicians, no matter what gender, colour, or age.
Using what initially seems to be the reluctant experience of a five-day retreat as the common thread throughout the book, Horton goes back and forward in time and space, connecting her own struggles with the deep conversations and stories of physicians she met during that week. In that supportive environment, Horton peeled away the many layers of her moral distress, guilt, and self-blame, shaking her belief that she was not the parent she should or could have been, the perception that she didn’t do enough for her patients, and the unfairness of what happened to her siblings and parents. All of that, plus the never relenting demands on her as a clinician and academic administrator, had pushed her into a pit full of burnout symptoms.
Writing this book was part of Horton’s own healing and rediscovery. It also serves as a mirror, not only for each of us as individual physicians, but also for all of us as a profession. Reading the book compels us to go on our own journey of self-discovery, to find the demons of perfectionism and work addiction that never allow us to really “turn off” unless we are willing to accept the guilt that comes with that.
The richness of metaphors and descriptions create images and bring feelings to life. For example, “How many times in our lives do we have a pager that felt like a live grenade?” Horton said she was fine in so many different ways and so many times when she wasn’t fine, that she came to believe it. As a result, she was not really in her life anymore and needed to find a way back into it. Her autobiography is for all physicians who have suffered in silence and need to find a way back into their own lives.
In the process of self-discovery, Horton understood the importance of self-compassion, particularly after she came to realize that the only person she seemed to be totally unwilling to help was herself. Her learning helps us realize that medicine should be neither a hero’s journey nor a Stanford prison experiment. Both mental models explain the high rate of burnout among physicians; the culture and the structure of the health care system and our own self-concepts as physicians lead to burnout. This means that we cannot change the system without dealing with our own beliefs and behaviour, but also that mindfulness alone can never fix systemic and organizational malformations in structure and culture.
The book finishes with a reflection on the times before and during the COVID crisis: “These are frightening times, when we are all struggling to keep the pieces of our lives from shattering into fragments, wondering what’s left if they do shatter, and how we will ever return to the life we had before. We’re never, ever going back. The minute we accept this is when our next life begins.” This is one of the most important quotes of the book. It applies to any complex adaptive system — from the individual human who learns and changes continuously to the natural and human-made complex systems transforming and adapting in a never-ending process.
Listen to a CSPL podcast interview of Dr. Jillian Horton with Dr. Van Aerde
https://leading-the-way.simplecast.com/episodes/interview-with-dr-jill-horton
Dr. Horton will also be a masterclass speaker at the 2021 Canadian Conference on Physician Leadership
https://physicianleadershipconference.com/ccpl2021.html
Without Compassion, There Is No Healthcare: Leading with Care in a Technological Age
Brian D. Hodges, Gail Paech, and Jocelyn Bennett (editors)
McGill-Queen’s University Press, 2020
Reviewed by J. Van Aerde, MD, PhD
Compassion means “suffering with” and comes from the Latin “com” (with) and “pati” (to suffer). That means that compassion requires human presence; it is a relationship. If we value presence, it becomes problematic when technologies distract, displace, or diminish humans in their connections with each other. Compassionate care has always been vulnerable when threatened by the constant imperative to be efficient, the mountains of scientific publications, and the rapid expansive logic of automation. That vulnerability is now bigger than ever. The authors make a strong argument that when compassion is diminished, health care becomes ineffective or even harmful to those who receive treatment, as well as those who provide it.
This book makes us rethink many of our assumptions, beliefs, and mental models. The definition of compassionate care itself is challenged. We assume that we practise compassionate care, but the book asks us to think again. By whom was compassion defined and how does it apply to different situations? It was defined mostly by those at the giving end of health care, mostly without various situational contexts in mind, particularly inequity. What does compassion mean for those who were not involved in that definition, and is the care then truly experienced as compassionate?
Compassionate care has four elements: being aware of suffering (others and self); the knowledge or cognition of that suffering; the feeling of how that suffering is experienced by the other, i.e., empathy; and the action to relieve the suffering. The difference between empathy and compassion is the action. The integrated understanding of the physical, biochemical, physiological, psychological, mental, social, cultural, and spiritual aspects of the other is an additional key element in compassionate care in the health care setting.
The changes in professional work in health care, which had started before and were accelerated by the COVID-19 crisis, will likely run deep, extending beyond routine tasks. They will disrupt the very foundation of the professions. After it is all over, will AI play a meaningful role in listening empathically, understanding deeply, or offering comfort? And if technology can’t do that, perhaps not ever, then how can it serve us to improve our relationships, our compassion, and our care? If compassion is fundamental in health care, then what deployment of human abilities and what technologies together will be most effective? Can AI ameliorate relationship-centred care and, if so, how? What are the implications for stress on the providers who are already stressed by EMRs? Will we need AI engineers as team members? What would be the impact on our professional liability insurance?
The connections between relationships, compassion for self and others, and burnout are described with the pandemic in the background. The current epidemic of burnout among health professionals is described as largely driven by diminution of human contact in our work environment. Relationships are integral to fostering resilience and protection against burnout. Health care work will face an enormous crisis if there is continued erosion of human presence and interaction. The physical distance between professionals and the people they care for has been growing, as more and more technologies become intermediaries between clinician and patient. It started with the stethoscope, followed by the X-ray machine, then MRIs, and now the computer for virtual appointments. What is the effect on the patient, on the relationship, and on clinicians’ own well-being?
The book finishes with compassionate leadership — what it takes to lead oneself, others, and organizations to make compassion a way of being within a safe work environment. Finally, embedding compassion and compassionate care into the structure and culture of health care organizations is also explored.
The book would have been more complete with a final chapter on how to change our complex health care system to see compassion in all its corners, levels, and connections.
Our biggest challenge is to decode the foundational elements of health care that will remain true, now and after the pandemic, even if AI takes over specific tasks of delivering that work. This book is a must read.
Dr. Brian D. Hodges will be a keynote speaker at the 2021 Canadian Conference on Physician Leadership
https://physicianleadershipconference.com/ccpl2021.html
Hardwired: How Our Instincts to Be Healthy Are Making Us Sick
Robert S. Barrett and Louis Hugo Francescutti
Copernicus Books, 2021
Reviewed by J. Van Aerde, MD, PhD
The authors provide plenty of evidence suggesting that we have entered a public health emergency in which our physiological and psychological well-being are failing to keep up with the fast pace of societal and technological change. Our survival instincts served us well until sometime in the last century. More recently, particularly in the last decade, those same hardwired survival instincts have been working against us as they have become immersed in an intoxicatingly rich environment of overstimulation and overindulgence. To survive, evolution linked instant gratification with items we needed to survive. But how does our biology deal with a new environment (in the western world) where stimuli are never ending, where the offerings of food and social bonding are endless?
With a richness of examples and evidence-based references, Barrett and Francescutti describe how our behaviour makes hospitals dangerous places and how our nutrition-related cravings affect our health negatively. Some less well-known information is found in the chapters “Raising children on war, cartoons, and social media” and “Are we hardwired for risk?” For those who tend to skip introductions to books, please read the very well written introduction summarizing the content of this one.
Building adaptive solutions to these modern challenges requires a combination of social and medical awareness. First, we need to understand why we do the things we do. Only after acquiring that awareness can we take action, holistically, by seeing our social and biological worlds as an integrated complex system.
Humans have a prefrontal cortex, the executive part of our brain. It allows us to control our self-destructive urges, by being aware, and by planning and strategizing to manage them. It is our way of overcoming short-term urges to achieve long-term goals. It is the evolutionary part of our brain that can help us reverse the recent destructive trend in health and wellness. The question is, do we have the will to use that uniquely human capacity to postpone immediate gratification for future health and wellness?
Stress in Medicine: Lessons Learned Through My Years as a Surgeon, from Med School to Residency and Beyond
Nina Ahuja, MD
Docs in Leadership, 2020
Reviewed by J. Van Aerde, MD, PhD
This small book is practical and contains reflections from Nina Ahuja based on her experiences during residency, in her personal life, and as a clinician and established academician. She provides many gems to reflect on, particularly for the emerging physician leader who is looking for something that resonates.
She developed her own framework for dealing with the stresses we physicians feel in professional and personal life. Her mnemonic ADMIT stands for: adapting to new ways, doing the work, measuring success, introspection, and transformation. The book finishes by highlighting the importance of a social support system. A quick worthwhile read. Top
Author
Johny Van Aerde, MD, PhD, FRCPC, is founding editor of the Canadian Journal of Physician Leadership and executive medical director of the Canadian Society of Physician Leaders.
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