ARTICLE

Psychological health and safety in health care: what do doctors have to do with it? Laura L. Calhoun, MD

 

 

Psychological health and safety in health care: what do doctors have to do

with it?

Laura L. Calhoun, MD

 

Good quality patient care is something all physicians care about. The links between high-quality patient care, the psychological well-being of physicians, and psychological health and safety on health care teams are becoming increasingly clear. This article examines these links and defines psychological health and safety and how they are interdependent. It clarifies the tremendously important role of physicians in setting the stage for psychological safety on their teams and offers some potential ways forward.

 

KEY WORDS: psychological safety, psychological health, physician burnout, physician leadership, joy in work

 

 

I remember, as a medical student on an O&G rotation, being scared to death of the attending physician. He was a man my father’s age, who had a reputation for scorning medical students if they made the slightest mistake and sometimes even before they made a mistake. I remember being frozen with fear when I, along with the female fourth-year resident, was helping a woman deliver a baby, and he came into the room and demanded to know “Why was I not called earlier?” in a booming voice.

 

No one said a word. He muscled the resident out of the way and said to both of us, “Stand back, doctors, just stand back.” He proceeded to do exactly what we had been doing, muttering under his breath the whole time. By then the head had crowned, and there was very little left to do but wait, deliver the rest of the baby and the placenta, and sew up the episiotomy, something even I could do by then. I was so relieved when he left the ward, and I could sense the tension leaving everyone who was on duty at

the time.

 

I didn’t know it then, but I know now: this is the kind of behaviour that creates unsafe work environments. To think that the resident or I would call this attending physician if one of the patients on the labour floor needed something that night was laughable. We just went ahead and did what we had to do and never called him. Luckily nothing went wrong and none of the nurses “ratted us out.”

 

I am willing to bet that every medical student has a story like this — at least one. I can easily recall three or four other such examples involving different physicians at different times when I was a student and a resident.

 

Of course, it is not just physicians who can display this type of disruptive behaviour. Anyone on the team can behave in a way that makes other members uncomfortable, or feel as if they need to walk on eggshells.

 

Have times changed? Are medical students, residents, nurses, and other health care professionals feeling safer while at work? Not from the anecdotes I’ve heard.

 

The vast majority of physicians and health care professionals behave well with their teams and intentionally create psychological safety every day. They do this by vocalizing their desire for teamwork. “We need all hands on deck today. I am open to hearing from all of you any ideas you have.” Or “I am really tired today and I am going to need everyone to help me make sure I don’t miss something. Please feel free to voice your thoughts and suggestions,” or “Who is running point on this case? What do you need from the rest of us to be successful?”

 

Being a true team player means creating, validating, and acknowledging interdependence. Other team members need you, and you need them to get the job done well. Many physicians are good team players and comfortable with interdependence. Some are good team players only when they are completely psychologically healthy, and some are not team players at all. Top

 

What is psychological safety in the workplace?

“A psychologically healthy and safe workplace is one that promotes workers’ psychological well-being and actively works to prevent harm to worker psychological health due to negligent, reckless or intentional acts.”1

 

Amy Edmonson2 defines psychological safety somewhat differently: “a shared belief that the team is safe for interpersonal risk taking.” She differentiates between psychological safety and trust in her research on teams. She teaches us that trust requires one person to think about another person’s behaviour, whereas psychological safety requires one person to think about his or her own behaviour.

 

An example is useful. If I don’t trust you, I am monitoring your behaviour to keep myself safe. If I don’t feel psychologically safe around you, I am monitoring my own behaviour to ensure I don’t do something that provokes you into making me feel stupid, ashamed, or “less than.” Edmonson clarifies that psychological safety on teams is in the hands of the leader, in that he or she can easily set the stage for team members to know they will not be made to feel “less than” should they ask a question or make a mistake.

 

Edmonson’s research, from the late 1990s, has been largely carried out using hospital-based teams and shows that psychological safety is an interpersonal team dynamic that is understood consistently by all members of a team; each person on the team has the same understanding of how safe it is to speak up, ask a question, or notice an error. Teams with high levels of psychological safety are more innovative, learn together, and have a greater sense of work satisfaction and a feeling of engagement.2

 

Psychological safety can be measured using a variety of tools developed for this purpose. The Guarding Minds at Work Survey3 was created at the Centre for Applied Research in Mental Health and Addiction. This is a free, easily accessible resource that can be used by any type of organization to establish a baseline or measure changes in safety culture as a result of intervention.

 

Psychological safety on health care teams, then, may hinge on physicians if they are seen or see themselves as the leader of the team.

 

What is psychological well-being?

Like physical well-being, psychological well-being exists on a continuum from healthy to ill, with infinite points in between. Psychological health comprises our ability to think, feel, and behave effectively at work, home, and in our social lives.4

 

How physicians and other health care workers feel emotionally fluctuates throughout the day depending on a multiplicity of factors, including how well they are physically, how fatigued they are, their mood in the moment, and the climate in which they are working. Health care workers who have been through traumatic events involving medical error without the necessary supports to return to full health are particularly at risk of burnout.5

 

The term “burnout” refers to an area on the psychological health continuum that could be termed “impaired,” “ill,” or “injured.” Team members who are injured, ill, or impaired can hurt more than help their teams.6 Recently, there is increasing awareness of physician burnout, which is traditionally measured by the Maslach burnout inventory (MBI). The MBI measures three domains: level of emotional exhaustion, frequency of experiencing depersonalization, and perception of decreased accomplishment. The syndrome of burnout has many consequences for individuals including physical illness, increased feelings of hopelessness, irritability, impatience, and poor interpersonal relationships. When severe, burnout can lead to diminished ability to work effectively.7  Top

 

Behaviours that result from physician burnout are similar to those that result from physicians suffering with major depression and include “withdrawing from responsibility, procrastinating, using food, drugs or alcohol to cope, taking frustration out on others, arriving late or leaving early, making more errors, isolating from others or depending more on others to complete work tasks.”8

 

Reducing burnout in physicians requires changes at the personal, structural, and organizational levels of health care.9

 

How do psychological health and psychological safety go together?

Although, at first glance, psychological health and safety can be viewed as separate constructs, it is helpful to think of them as interdependent. Psychologically healthy leaders are much more likely to create psychologically safe team dynamics. When we are well slept and look forward to our day at work, we have more mental energy to expend on treating other people well. As we move along the mental health continuum from healthy to fatigued to stressed to injured, it becomes harder for us to think, feel, and behave effectively. Our mental energy is expended quickly on just getting through the day with little left over in the way of empathy or compassion.

 

At the same time, psychologically unsafe workplaces can worsen our mental health. Walking on eggshells, being mindful of the invisible line between provoking anger in others and speaking up is stressful. Asking a question or making an observation that is reacted to in a way that makes you feel incompetent can worsen mood or increase anxiety. These types of workplace stress can be chronic if left unaddressed. Chronic stress at work is a risk factor for psychological injury and mental illness. Top

 

Finally, when we recognize that we are psychologically unwell, we are often afraid to talk about it because of the stigma — the worry that we look weak, lose the respect of others that we crave, and perhaps even lose our jobs.1

 

A creative way forward?

The Institute for Healthcare Improvement (IHI) has taken the need for psychological health and safety in health care as a foundational prerequisite for an initiative they call “joy in work.”10 Using Maslow’s hierarchy of needs for comparison, they note that safety is a primary need for individuals to thrive both in their lives and in their work.

 

The IHI’s white paper10 cites numerous studies that point to the same conclusion: when physicians and other health care workers are not emotionally well, they cannot provide good-quality patient care. “You cannot give what you don’t have” is a quote Don Berwick uses in the white paper’s opening comments. The link between physician burnout and patient quality care may be, in part, workplace psychological safety.

 

Quality of patient care is something every physician cares about. Helping people get well and stay well are reasons why people are drawn to medicine in the first place. It is what ignited our passion and keeps us motivated to attend continuing medical education, refine our skills, and research best practices.

 

Although the role of medical expert is assumed to be key to a good physician, other skills are equally important including the ability to create and maintain healthy interpersonal relationships on teams. Healthy relationships require the ability to be vulnerable and to admit to, notice, and acknowledge one’s own fallibility. If the role of medical expert is valued more highly than others, such as self-awareness and team player, physicians may act unprofessionally without consequence. Top

 

Quality of patient care is improved when health care professionals are psychologically well, maintain good interpersonal relationships, and acknowledge interdependence within their teams.10 This sets the stage for a psychologically healthy workplace where every member of the team feels safe to speak up, ask questions, and learn.

 

IHI has taken a novel approach with its joy in work initiative by aiming its recommendations at the level of the health care team and by using appreciative inquiry to investigate interpersonal dynamics. IHI asks that leaders begin by asking their direct reports “what matters to you?” as a conversation starter that leads to discovery of ideas for increasing joy at work that can be co-created, quickly tested, measured, and either kept or discarded. IHI’s initiative builds on the quality improvement method of “plan-do-study-act” cycles that is familiar to physicians and health care organizations.

 

Is physician leadership skill a key to psychological safety on health care teams?

Physicians often perceive or assume that they are the most responsible provider on the team, which can lead to a sense that they are the de facto team leader. As we move toward team care practice, this perception may wane, but currently physicians are often the person for whom the rest of the team is waiting to discuss and decide on the next step in treatment, the care plan, the need for follow up. When physicians are perceived or assumed to be the team lead, they set the stage for the culture of the team through their ability to create and maintain a healthy interpersonal dynamic that allows every team member to be a full participant.

 

The IHI’s joy in work initiative, recognizing that leaders set the culture, bases its recommendation on health care leaders taking action. Although physicians are seen as leaders on their teams, many have not had the benefit of leadership skill training required to set a positive, safe climate where team members feel comfortable being themselves and speaking freely. Top

 

One possible mechanism for improving psychological safety and quality of patient care, then, is basic physician leadership training that emphasizes aspects of emotional intelligence, such as self-awareness, self-management, and self-development. This training could help physicians stay psychologically well themselves through its emphasis on resilience, balance, and personal mastery.11

 

The links between the triad of psychological health and safety, physician wellness, and quality patient care are being clarified. Physician training in basic leadership skills offers one possible way forward that has the potential to positively affect all three aspects of this triad. Doctors have everything to do with psychological health and safety in health care.

 

References

1.Gilbert M, Bilsker D, Samra J, Shain M. Distinguishing mental injury, mental distress and mental illness. Vancouver: Centre for Applied Research in Mental Health and Addiction, Simon Fraser University; 2018. Available: https://tinyurl.com/ycfpuet6

2.Edmonson AC. Psychological safety, trust and learning in organizations: a group-level lens. In Kramer R, Cook K (editors). Trust and distrust in organizations: dilemmas and approaches. New York: Russell Sage Foundation; 2004. pp. 239-72.

3.Guarding minds at work: a workplace guide to psychological health and safety. Vancouver: Centre for Applied Research in Mental Health & Addiction, Simon Fraser University; n.d. Available: https://www.guardingmindsatwork.ca/

4.Mental health: strengthening our response. Geneva: World Health Organization; 2018. Available: https://tinyurl.com/ydybluh6

5.Wu AW. Medical error: the second victim. BMJ 2000;320:726. https://doi.org/10.1136/bmj.320.7237.726

6.Gilbert M, Bilsker D, Samra J, Shain M. Possible threats to psychological safety: employee privacy and employer responsibility. Vancouver: Centre for Applied Research in Mental Health and Addiction; 2018. Available: https://tinyurl.com/y8ng5tuk

7.Maslach C, Leiter MP. Reversing burnout: how to rekindle your passion for your work. Standford Soc Innov Rev  2005;winter. Available: https://tinyurl.com/y84fddb3 (accessed 29 Mar. 2018).

8.Pomaki G. The ABCs of psychological safety in the workplace. Toronto: Canadian Centre for Ethics and Corporate Policy; n.d. Available: https://tinyurl.com/qblkg29 (accessed 26 Mar. 2018)

9.West CP, Liselotte N, Dyrbye P, Erwin J, Shanafelt T. Interventions to prevent and reduce burnout: a systematic review and meta-analysis. Lancet 2016 http://dx.doi.org/10.1016/S0140-6736(16)31279-X

10.Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI framework for improving joy in work (white paper). Cambridge, Mass.: Institute for Healthcare Improvement; 2017.

11.Lead self: the root of the matter: what every health leader should know. Ottawa: LEADS Canada; n.d. https://tinyurl.com/y9tt9m8p

 

Author

Laura L. Calhoun MD, FRCPC, MAL(H), CEC, practises psychiatry and has a role as a physician leader in Alberta Health Services. Top

 

Correspondence to: lauraloucalhoun@gmail.com

 

This article has been peer reviewed.

 

Psychological health and safety in health care: what do doctors have to do

with it?

Laura L. Calhoun, MD

 

Good quality patient care is something all physicians care about. The links between high-quality patient care, the psychological well-being of physicians, and psychological health and safety on health care teams are becoming increasingly clear. This article examines these links and defines psychological health and safety and how they are interdependent. It clarifies the tremendously important role of physicians in setting the stage for psychological safety on their teams and offers some potential ways forward.

 

KEY WORDS: psychological safety, psychological health, physician burnout, physician leadership, joy in work

 

 

I remember, as a medical student on an O&G rotation, being scared to death of the attending physician. He was a man my father’s age, who had a reputation for scorning medical students if they made the slightest mistake and sometimes even before they made a mistake. I remember being frozen with fear when I, along with the female fourth-year resident, was helping a woman deliver a baby, and he came into the room and demanded to know “Why was I not called earlier?” in a booming voice.

 

No one said a word. He muscled the resident out of the way and said to both of us, “Stand back, doctors, just stand back.” He proceeded to do exactly what we had been doing, muttering under his breath the whole time. By then the head had crowned, and there was very little left to do but wait, deliver the rest of the baby and the placenta, and sew up the episiotomy, something even I could do by then. I was so relieved when he left the ward, and I could sense the tension leaving everyone who was on duty at

the time.

 

I didn’t know it then, but I know now: this is the kind of behaviour that creates unsafe work environments. To think that the resident or I would call this attending physician if one of the patients on the labour floor needed something that night was laughable. We just went ahead and did what we had to do and never called him. Luckily nothing went wrong and none of the nurses “ratted us out.”

 

I am willing to bet that every medical student has a story like this — at least one. I can easily recall three or four other such examples involving different physicians at different times when I was a student and a resident.

 

Of course, it is not just physicians who can display this type of disruptive behaviour. Anyone on the team can behave in a way that makes other members uncomfortable, or feel as if they need to walk on eggshells.

 

Have times changed? Are medical students, residents, nurses, and other health care professionals feeling safer while at work? Not from the anecdotes I’ve heard.

 

The vast majority of physicians and health care professionals behave well with their teams and intentionally create psychological safety every day. They do this by vocalizing their desire for teamwork. “We need all hands on deck today. I am open to hearing from all of you any ideas you have.” Or “I am really tired today and I am going to need everyone to help me make sure I don’t miss something. Please feel free to voice your thoughts and suggestions,” or “Who is running point on this case? What do you need from the rest of us to be successful?”

 

Being a true team player means creating, validating, and acknowledging interdependence. Other team members need you, and you need them to get the job done well. Many physicians are good team players and comfortable with interdependence. Some are good team players only when they are completely psychologically healthy, and some are not team players at all. Top

 

What is psychological safety in the workplace?

“A psychologically healthy and safe workplace is one that promotes workers’ psychological well-being and actively works to prevent harm to worker psychological health due to negligent, reckless or intentional acts.”1

 

Amy Edmonson2 defines psychological safety somewhat differently: “a shared belief that the team is safe for interpersonal risk taking.” She differentiates between psychological safety and trust in her research on teams. She teaches us that trust requires one person to think about another person’s behaviour, whereas psychological safety requires one person to think about his or her own behaviour.

 

An example is useful. If I don’t trust you, I am monitoring your behaviour to keep myself safe. If I don’t feel psychologically safe around you, I am monitoring my own behaviour to ensure I don’t do something that provokes you into making me feel stupid, ashamed, or “less than.” Edmonson clarifies that psychological safety on teams is in the hands of the leader, in that he or she can easily set the stage for team members to know they will not be made to feel “less than” should they ask a question or make a mistake.

 

Edmonson’s research, from the late 1990s, has been largely carried out using hospital-based teams and shows that psychological safety is an interpersonal team dynamic that is understood consistently by all members of a team; each person on the team has the same understanding of how safe it is to speak up, ask a question, or notice an error. Teams with high levels of psychological safety are more innovative, learn together, and have a greater sense of work satisfaction and a feeling of engagement.2

 

Psychological safety can be measured using a variety of tools developed for this purpose. The Guarding Minds at Work Survey3 was created at the Centre for Applied Research in Mental Health and Addiction. This is a free, easily accessible resource that can be used by any type of organization to establish a baseline or measure changes in safety culture as a result of intervention.

 

Psychological safety on health care teams, then, may hinge on physicians if they are seen or see themselves as the leader of the team.

 

What is psychological well-being?

Like physical well-being, psychological well-being exists on a continuum from healthy to ill, with infinite points in between. Psychological health comprises our ability to think, feel, and behave effectively at work, home, and in our social lives.4

 

How physicians and other health care workers feel emotionally fluctuates throughout the day depending on a multiplicity of factors, including how well they are physically, how fatigued they are, their mood in the moment, and the climate in which they are working. Health care workers who have been through traumatic events involving medical error without the necessary supports to return to full health are particularly at risk of burnout.5

 

The term “burnout” refers to an area on the psychological health continuum that could be termed “impaired,” “ill,” or “injured.” Team members who are injured, ill, or impaired can hurt more than help their teams.6 Recently, there is increasing awareness of physician burnout, which is traditionally measured by the Maslach burnout inventory (MBI). The MBI measures three domains: level of emotional exhaustion, frequency of experiencing depersonalization, and perception of decreased accomplishment. The syndrome of burnout has many consequences for individuals including physical illness, increased feelings of hopelessness, irritability, impatience, and poor interpersonal relationships. When severe, burnout can lead to diminished ability to work effectively.7  Top

 

Behaviours that result from physician burnout are similar to those that result from physicians suffering with major depression and include “withdrawing from responsibility, procrastinating, using food, drugs or alcohol to cope, taking frustration out on others, arriving late or leaving early, making more errors, isolating from others or depending more on others to complete work tasks.”8

 

Reducing burnout in physicians requires changes at the personal, structural, and organizational levels of health care.9

 

How do psychological health and psychological safety go together?

Although, at first glance, psychological health and safety can be viewed as separate constructs, it is helpful to think of them as interdependent. Psychologically healthy leaders are much more likely to create psychologically safe team dynamics. When we are well slept and look forward to our day at work, we have more mental energy to expend on treating other people well. As we move along the mental health continuum from healthy to fatigued to stressed to injured, it becomes harder for us to think, feel, and behave effectively. Our mental energy is expended quickly on just getting through the day with little left over in the way of empathy or compassion.

 

At the same time, psychologically unsafe workplaces can worsen our mental health. Walking on eggshells, being mindful of the invisible line between provoking anger in others and speaking up is stressful. Asking a question or making an observation that is reacted to in a way that makes you feel incompetent can worsen mood or increase anxiety. These types of workplace stress can be chronic if left unaddressed. Chronic stress at work is a risk factor for psychological injury and mental illness. Top

 

Finally, when we recognize that we are psychologically unwell, we are often afraid to talk about it because of the stigma — the worry that we look weak, lose the respect of others that we crave, and perhaps even lose our jobs.1

 

A creative way forward?

The Institute for Healthcare Improvement (IHI) has taken the need for psychological health and safety in health care as a foundational prerequisite for an initiative they call “joy in work.”10 Using Maslow’s hierarchy of needs for comparison, they note that safety is a primary need for individuals to thrive both in their lives and in their work.

 

The IHI’s white paper10 cites numerous studies that point to the same conclusion: when physicians and other health care workers are not emotionally well, they cannot provide good-quality patient care. “You cannot give what you don’t have” is a quote Don Berwick uses in the white paper’s opening comments. The link between physician burnout and patient quality care may be, in part, workplace psychological safety.

 

Quality of patient care is something every physician cares about. Helping people get well and stay well are reasons why people are drawn to medicine in the first place. It is what ignited our passion and keeps us motivated to attend continuing medical education, refine our skills, and research best practices.

 

Although the role of medical expert is assumed to be key to a good physician, other skills are equally important including the ability to create and maintain healthy interpersonal relationships on teams. Healthy relationships require the ability to be vulnerable and to admit to, notice, and acknowledge one’s own fallibility. If the role of medical expert is valued more highly than others, such as self-awareness and team player, physicians may act unprofessionally without consequence. Top

 

Quality of patient care is improved when health care professionals are psychologically well, maintain good interpersonal relationships, and acknowledge interdependence within their teams.10 This sets the stage for a psychologically healthy workplace where every member of the team feels safe to speak up, ask questions, and learn.

 

IHI has taken a novel approach with its joy in work initiative by aiming its recommendations at the level of the health care team and by using appreciative inquiry to investigate interpersonal dynamics. IHI asks that leaders begin by asking their direct reports “what matters to you?” as a conversation starter that leads to discovery of ideas for increasing joy at work that can be co-created, quickly tested, measured, and either kept or discarded. IHI’s initiative builds on the quality improvement method of “plan-do-study-act” cycles that is familiar to physicians and health care organizations.

 

Is physician leadership skill a key to psychological safety on health care teams?

Physicians often perceive or assume that they are the most responsible provider on the team, which can lead to a sense that they are the de facto team leader. As we move toward team care practice, this perception may wane, but currently physicians are often the person for whom the rest of the team is waiting to discuss and decide on the next step in treatment, the care plan, the need for follow up. When physicians are perceived or assumed to be the team lead, they set the stage for the culture of the team through their ability to create and maintain a healthy interpersonal dynamic that allows every team member to be a full participant.

 

The IHI’s joy in work initiative, recognizing that leaders set the culture, bases its recommendation on health care leaders taking action. Although physicians are seen as leaders on their teams, many have not had the benefit of leadership skill training required to set a positive, safe climate where team members feel comfortable being themselves and speaking freely. Top

 

One possible mechanism for improving psychological safety and quality of patient care, then, is basic physician leadership training that emphasizes aspects of emotional intelligence, such as self-awareness, self-management, and self-development. This training could help physicians stay psychologically well themselves through its emphasis on resilience, balance, and personal mastery.11

 

The links between the triad of psychological health and safety, physician wellness, and quality patient care are being clarified. Physician training in basic leadership skills offers one possible way forward that has the potential to positively affect all three aspects of this triad. Doctors have everything to do with psychological health and safety in health care.

 

References

1.Gilbert M, Bilsker D, Samra J, Shain M. Distinguishing mental injury, mental distress and mental illness. Vancouver: Centre for Applied Research in Mental Health and Addiction, Simon Fraser University; 2018. Available: https://tinyurl.com/ycfpuet6

2.Edmonson AC. Psychological safety, trust and learning in organizations: a group-level lens. In Kramer R, Cook K (editors). Trust and distrust in organizations: dilemmas and approaches. New York: Russell Sage Foundation; 2004. pp. 239-72.

3.Guarding minds at work: a workplace guide to psychological health and safety. Vancouver: Centre for Applied Research in Mental Health & Addiction, Simon Fraser University; n.d. Available: https://www.guardingmindsatwork.ca/

4.Mental health: strengthening our response. Geneva: World Health Organization; 2018. Available: https://tinyurl.com/ydybluh6

5.Wu AW. Medical error: the second victim. BMJ 2000;320:726. https://doi.org/10.1136/bmj.320.7237.726

6.Gilbert M, Bilsker D, Samra J, Shain M. Possible threats to psychological safety: employee privacy and employer responsibility. Vancouver: Centre for Applied Research in Mental Health and Addiction; 2018. Available: https://tinyurl.com/y8ng5tuk

7.Maslach C, Leiter MP. Reversing burnout: how to rekindle your passion for your work. Standford Soc Innov Rev  2005;winter. Available: https://tinyurl.com/y84fddb3 (accessed 29 Mar. 2018).

8.Pomaki G. The ABCs of psychological safety in the workplace. Toronto: Canadian Centre for Ethics and Corporate Policy; n.d. Available: https://tinyurl.com/qblkg29 (accessed 26 Mar. 2018)

9.West CP, Liselotte N, Dyrbye P, Erwin J, Shanafelt T. Interventions to prevent and reduce burnout: a systematic review and meta-analysis. Lancet 2016 http://dx.doi.org/10.1016/S0140-6736(16)31279-X

10.Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI framework for improving joy in work (white paper). Cambridge, Mass.: Institute for Healthcare Improvement; 2017.

11.Lead self: the root of the matter: what every health leader should know. Ottawa: LEADS Canada; n.d. https://tinyurl.com/y9tt9m8p

 

Author

Laura L. Calhoun MD, FRCPC, MAL(H), CEC, practises psychiatry and has a role as a physician leader in Alberta Health Services. Top

 

Correspondence to: lauraloucalhoun@gmail.com

 

This article has been peer reviewed.