Volume 7 no 2
PERSPECTIVE: No person left behind: improving physician wellness in Canada
Jason Chaulk, MD
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PERSPECTIVE: No person left behind: improving physician wellness in Canada
Jason Chaulk, MD
https//doi.org/10.37964/cr24730
Canadian health care costs are unsustainable and are among the highest in the world. A greater focus on system-level initiatives is needed, and recognizing physician wellness as a quality indicator for health care delivery may be part of the solution. Physicians’ psychosocial health is a significant cause for concern and has been directly tied to patient outcomes. However, suicide rates among physicians are approximately 2.5 times those of the general population and burnout rates are twice those of other workforces. Investing in physician health programs (PHPs), specifically the components dealing with psychosocial issues, is one way to make medicare sustainable. Further, greater provincial government support of national guidelines for the formation of PHPs is needed. This commentary focuses on these background issues and suggests a path toward a more sustainable health care strategy focusing on physician well-being.
KEY WORDS: mental health, burnout, medicare, health promotion, suicide, public health, physician impairment, physician self-referral, quality indicators, health care
CITATION: Chaulk J, No person left behind: improving physician wellness in Canada. Can J Physician Leadersh 2021;7(2):67-71.
To say that Canada’s health care system is “hopelessly sclerotic” may appear overly harsh. However, Neil MacDonald makes that statement in a 2019 article, in which he describes his experience with the system.1 All too often, Canadians are starting their days reading about the crisis our medicare system is facing. The Canadian Medical Association (CMA) highlights this reality when it states that “Canada’s prized Medicare system is facing serious challenges on two key fronts: in meeting the legitimate health care needs of Canadians and in being affordable for the public purse.”2 Sobering statistics back these opinions. In 2009, the EuroCanada health consumer index ranked Canada last among 30 countries in terms of health care efficiency.3 Couple this with the fact that we spend 11.3% of our gross domestic product on health care alone, and the situation is clear.3
Adjusting the aim
To solve this crippling state of affairs, the Institute for Healthcare Improvement developed the Triple Aim framework.4 It recommends that stakeholders examine three dimensions of health care performance: improving the health of populations, enhancing the patient’s experience of care, and reducing the per capita cost of health care.5 However, meeting these dimensions is reportedly pushing many health care providers, specifically physicians, toward burnout and reducing the chance of successful implementation.6 The psychosocial strain that this framework places on physicians is concerning. As a physician with lived experience, I can understand the effect that poor psychosocial health can have on both one’s professional and personal lives. Top
Evidence shows that poor physician mental health is linked to lower patient satisfaction, reduced health outcomes, and increased costs.7 As Wallace et al.8 discuss, poor health and inappropriate coping mechanisms may result in increased clinical errors and impede a physician’s ability to counsel patients on healthy lifestyle behaviours.
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A missed indicator Top
Evidence indicates that physician well-being is emerging as a significant quality indicator for health care system performance. Although obscured by the fact that physicians are often physically healthier than the general population, their mental health status is poor.2 In Newfoundland and Labrador alone, a survey of approximately 500 physicians rated mental health as the number one priority area to be addressed by the Newfoundland and Labrador Medical Association (NLMA).10 As a result of this survey, and specific physician wellness situations, the NLMA created the Physician Care Network (PCN). Like other physician health programs (PHPs), the PCN’s mandate is to educate and promote the biological, psychological, social, and spiritual health of physicians in the province on their journey to a stronger self. I believe that following this model is a step toward reducing the stigma and stress that our local physicians face when seeking help.
Nationally, physician mental health is at a critical stage, with burnout rates double those of all other workforces.11 Rural areas are particularly stressed: up to 50% of rural physicians are experiencing serious burnout.12 Compounding this reality is the frightening statistic that physicians have completed suicide rates that are approximately 2.5 times those of the general population, and they are at an increased risk of debilitating depression.2 With 30% of physicians in Canada suffering from depression and only 33% having a family physician, is it a wonder that “the collective state of physician health remains a significant threat to the viability of Canada’s health system”?13 Top
Plan for action
To address this threat to patient care and health care sustainability, the CMA recognizes that a neoliberalist approach to health care is unreliable and that a more system-level approach is needed.2 Adopting a more holistic definition of health that recognizes physician wellness as an amalgam of social, biophysical, and community-based factors may be part of the solution.6 One way to begin is by having system-level influencers invest more capital in PHPs, specifically, the components dealing with psychosocial issues.
It is critical to establish structured organizational and system-level solutions, such as PHPs, to help physicians improve their well-being.13 Furthermore, universal access must be created to reduce the stigma around physician mental health, as 76% of Canadian physicians feel ashamed to seek help and fear reprisals from regulatory bodies.14 Such a goal could be met by creating national guidelines for PHPs and by placing them under the various provincial departments of health and community services. This approach would strengthen the acceptance of PHPs and point out the critical importance of tackling the physician health crisis. Top
Economics
Discussion of the economic burden of physician training strengthens the case for nationally guided PHPs. The average cost of training a medical student for four years in Canada is $260,000; for a resident, the cost is about $100,000 a year.15 In addition, approximately 30% of Canada’s physicians who suffer burnout contemplate leaving medicine; in the United States, approximately 42% of physicians contemplate withdrawing from full-time clinical practice or restricting their scope of practice.16
Statistical analysis has shown that a variety of stressors are adding to physician burnout and a desire to reduce work hours, with loss of control over clinical practice structure (odds ratio [OR] 1.81), implementation of the electronic medical record (OR 1.56), and poor work–life integration (OR 1.65) at the top of the list.17
If the current system goes unchallenged, it will not take long to see an economic effect.6 More alarming are data from a Canadian analysis that show that the cost of reduced work hours and early withdrawal from clinical practice secondary to burnout is $213 million.18 Top
Acknowledging that government-level support may be challenging, given the fiscal reality many provinces are currently facing, the federal government could set aside a component of provincial transfer payments to help support PHPs. Simultaneous implementation of a memorandum of understanding would ensure proper use of the funds and allow monitoring of outcomes.
Oversight
PHPs court controversy and have their detractors. Some physicians are concerned that PHPs are “diagnosing for dollars” and pushing self-referred physicians into expensive treatment programs.19 In a system where medical professionals pay for all treatment out-of-pocket and in which there are no standardized treatment costs, cracks exist, through which inappropriate actions can fester. This reality strengthens the need for nationally mandated operation standards and oversight of PHPs throughout Canada with an amalgam of public and physician-based funding. Such governance would help reduce stigma and inappropriate treatment of self-referring physicians and lead to increased community capital for physician well-being, quality of patient care, and fiscal outcomes. Top
As an example, the model developed by the Joint Reference Committee of the American Psychiatric Association could be applied to the Canadian system and help meet these goals.20 Such models cite a 75% success rate for American PHPs and are built on the premise that medical regulators must recognize the need for access to rehabilitation services, confidential support teams, and community resources specific to physicians’ mental health.2 They imply that physicians should not be penalized for seeking treatment. Why would we expect any less for our Canadian physicians?
Is there another option?
As health care costs continue to soar in North America, we would be remiss not to explore alternatives to PHPs that require moderately large capital infusions to get off the ground until physician membership and government budgets make them financially sustainable. Many large health care institutions across North America report that physician peer-support programs (PEERSPs) are useful “initial vehicles” to help meet a large majority of physician wellness needs. In fact, they reduce the number of referrals to more formal PHPs.21 Top
Specifically, PEERSPs are based on a supportive relationship between people who have a common lived experience. They have a mandate to provide psychologically safe, supportive, and empowering coping skills in a fully confidential manner.22 Lending support to the benefit of a PEERSP as an initial intervention for physicians is the fact that 98% of surveyed anesthesia providers felt that discussing adverse events with a peer was most effective, and 88% felt that it should be standard procedure.23 A larger survey21 showed that the well-established Mayo Clinic Office of Staff Services was accessed by 75% of their physicians, scientists, and senior administrators for financial counseling and 7% for peer support yearly.
A complete analysis of PEERSPs and their implementation is beyond the scope of this commentary; however, it is clear that when implemented with good organizational structure and when coupled with PHPs they are a strong weapon in the fight against physician unwellness. Any formal PHP in Canada should use a well-functioning PEERSP to help reduce financial costs and simultaneously reduce physician stigma attached to engaging in any wellness infrastructure. Top
Conclusion
With a Canada-wide call for increased social investment and funding of mental health promotion coming from such recognized bodies as the Canadian Mental Health Association and the Canadian Medical Foundation (CMF), the social milieu is at the right point for reducing physician health stigma and increasing system-level acknowledgment of the crisis of inefficiency and eroding quality of care facing our medicare system.24 As the CMF eludes to, our national associations, health authorities, medical regulators, and physicians must amalgamate their acceptance and interactions with PHPs by using a consistent framework to fulfill the health needs of all physicians while addressing a broad gap in the equity of and access to services.24 Furthermore, such a framework must focus on the high rates of burnout in rural areas and ensure that our rural physicians are not excluded from such initiatives.
With lived experience in the area of physician mental health, I can confirm the need for a robust PHP system to reduce the shame, fear, and financial burden that some current systems place on physicians who need assistance. Based on the limited discussion above, physician distress cannot be ignored, and we, as a nation, cannot avoid the challenges of securing one of our most precious cultural identities, public health care. Top
References
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13. CMA Board Working Group on Mental Health. Physician health matters: a mental health strategy for physicians in Canada. Canadian Medical Association. Ottawa: Canadian Medical Association; 2010.
14. Simon C, Mcfadden T. National Physician Health Survey: the process, preliminary data, and future directions. Ottawa: Canadian Medical Association; 2017.
15. Official Languages Community Development Bureau. Overview of the cost of training health professionals. Ottawa: Health Canada; 2008. Available: https://tinyurl.com/y6tu7pj4
16. Sinsky C, Dyrbye L, West C, Satele D, Tutty M, Shanafelt T. Professional satisfaction and the career plans of US physicians. Mayo Clin Proc 2017;92(11):1625-35. https://doi.org/10.1016/j.mayocp.2017.08.017
17. Olson KD. Physician burnout — a leading indicator of health system performance? Mayo Clin Proc 2017;92(11):1608-11. https://doi.org/10.1016/j.mayocp.2017.09.008
18. Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014;14(254):1-9. https://doi.org/10.1186/1472-6963-14-254
19. Miller D. Physician health programs: diagnosing for dollars? MDedge: Psychiatry 2017;5 Dec. Available: https://tinyurl.com/y4xf8qle
20.Workgroup of the Council on Psychiatry and Law. Resource document on recommended best practices for physician health programs. Washington, DC: American Psyschiatric Association; 2017. Available: https://tinyurl.com/y44qjde8
21. Shanafelt TD, Lightner DJ, Conley C, Petrou SP, Richardson JW, Schroeder PJ, et al. An organization model to assist individual physicians, scientists, and senior health care adminstrators with personal and professional needs. Mayo Clin Proc 2017;92(11):1688-96. https://doi.org/10.1016/j.mayocp.2017.08.020
22. Creating a safe space: section 4: Canadian best practice guidelines for peer to peer support programs. Ottawa: Canadian Patient Safety Institute; 2019. Available: https://tinyurl.com/u27p23p
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24. Tricoastal Consortium. A descriptive framework for physician health services in Canada. Ottawa: Canadian Medical Foundation; 2016. Available: https://tinyurl.com/yygodur9
Author
Jason Chaulk, MD, FRCPC, is staff anesthetist at Carbonear General Hospital in Carbonear, Newfoundland, and assistant rural faculty in the faculty of medicine, Memorial University of Newfoundland.
Correspondence to:
This article has been peer reviewed.