December 15, 2021

Burnout & Recovery: A Conversation with Dr. Jillian Horton

[Edited for grammar and clarity by CAMH]

[Musical intro]

David Gratzer: It's not depression, it's not complaining. And in the words of Dr. Frank Summers from the American Journal of Psychiatry, it's notoriously difficult to characterise. Physician burnout.

On this episode of Quick Takes: A podcast by Physicians for Physicians, we talk about it. I'm Dr. David Gratzer, psychiatrist here at the Centre for Addiction and Mental Health in Toronto. Joining us today, Dr. Jillian Horton, a general internist from Winnipeg who is also the associate chair of the Department of Internal Medicine at my alma mater, the University of Manitoba Faculty of Medicine, and she's a super prolific writer, including on the topic of physician burnout. Welcome, Dr. Horton.

Jillian Horton: It's lovely to be here with you today, David.

David Gratzer: Well, we appreciate you taking the time. First things first, how might you describe physician burnout?

Jillian Horton: Well, that's a wonderful question, because we know what the literature tells us. We think of this trifecta: depersonalisation, emotional exhaustion, and a low feeling of personal accomplishment. So that's what the "books" tell us to expect when we're burnt out. But when I look back at my own life and how I think it has manifested, it's often been much more subtle. And for me, you know, I may not have felt those things at work. I may not have experienced a sense of depersonalisation or a sense that my work didn't matter. But what I did notice, and not necessarily at the time because I never really called it burnout, was it looking back when I would get home at the end of my intense workdays and my long shifts on the wards, and particularly when I was doing my most intense clinical blocks, I would have nothing left. Nothing left for myself, nothing left for my spouse, nothing left for my children. I always say that they would get the leftover garbage scraps of me, and I think that for many of us, that's how burnout begins and that's how it manifests in our lives. We do everything we can to keep our performance high at work, but when it comes to our personal lives, it begins to atrophy and our personal life begins to suffer. So, for me, that's actually how I think of burnout, uncompensated burnout, as beginning to manifest, and certainly how I experienced it.

David Gratzer: And you've talked about this and you've written about this and you've social media following. Why did you choose to talk about this?

Jillian Horton: You know, I sometimes would read articles by our colleagues, Adam B. Hill in the U.S. is a is one who of course, has written very personal testimonial type work about his struggles with addiction and mental health. And the other pieces that I'd read when I often refer people to is Carrie Bernard's lovely piece called “Disclosure” in the CMAJ, where she wrote about why was it so hard for her to tell colleagues that she had depression when she diagnoses patients with the same illness every day? And I always had this feeling, you know, I'd read these pieces, I'd relate to them. I'd see something beautiful, powerful and important in them. But I had this feeling that, you know, my brave colleagues were just up there on a stage, speaking out to a room full of people. And the rest of us were just sort of out there feeling that we really related to what they were saying. But looking at our toes and not saying, you know, me too, or I also have a story. And I just hit a point that I knew with my communication skills and the time in my life that I had invested in becoming a serious and skilled writer. I felt that, you know, it's no longer right for me to just be the person out in the audience saying privately, Yes, that was really good. I'm so glad you were brave enough to do that. I thought it was time for me to become more brave and finally put my own story out there because I had just reached a point that I realised if I can't do this, how can anybody else? And I felt that maybe it would sequentially give other people a little bolus of bravery as well.

David Gratzer: Because doctors typically don't talk about these things, we're supposed to be "beyond human", right? But we're pretty human, in fact, aren't we?

Jillian Horton: Yeah, and I think that's absolutely true. And then I think the other piece of that is, you know, that one of the big things that I spent a lot of time doing now is teaching mindfulness to medical learners across the different stages of their careers and also to faculty. And I think that one of the things that happens to us in our training, I often talk about it as you know, we're taught to disembody. We are taught to work through our fatigue, our hunger, our intense emotions. We're not really taught to be mindful about those things and learn to coexist with them. We're taught to ignore them, to bury them deep. And so I think this has a series of unintended consequences that when we emerge at some point in our careers, you know, 10, 20, 30 years later and have been using that approach to deal with our physical exhaustion, our emotional pain, our conflicted feelings about so many of the things that we've had to face and do in our careers and personal lives. I think we suddenly come out not really knowing how to localise those things anymore. Having lost the vocabulary to describe them, and I think it's time for us as a profession to commit to getting that vocabulary back and to making it a very normal act for us to discuss, name, describe and learn to co-exist more peacefully with some of those experiences.

David Gratzer: And in your book, you talked very graphically about feeling at the end of your career. I mean, you talk at one point in time about being having the feeling the practise of medicine was in fact like being in a prison.

Jillian Horton: Mm-hmm. And I think, you know, there is this interesting analogy, I think when you look at how we are trained and conditioned. I mean, we go into medicine and by the time we start our clerkship, we suddenly have a period of years that we move into where we no longer have a lot of access for many of us. It's not the same for everyone, but I think this is a fairly universal experience, especially if we move to train somewhere else. All the previous social circles, the things that we were a part of, they begin to dwindle and recede. And suddenly the people that we're surrounded by are the other people having the same experience as us. And during those most difficult years of our residency, most of us actually, probably spend at least the same, if not more hours in the hospital than we do in our own homes with the symbols and artefacts of our old life. And I think by the end of that period of training – I mean, there's some good things that happen to us, for sure – we emerge really as totally different people, and I think many of us struggle to get used to that old life again. To rejoin that old life, we've become much more like the people that we spent all that time with, then the people that we used to spend all of our time with.

David Gratzer: When did you know you needed to do something?

Jillian Horton: Well, there were two major points of knowing for me, interestingly. One was during my residency I was suffering from pretty extreme burnout. And again, burnout wasn't really part of our vocabulary. That is, as you know, because you and I are really the same vintage. So, you know, when we talked about physician wellness or getting help, it was really like, if you were in crisis. Nobody cared if you were feeling burnt out or emotionally exhausted, that was sort of an expectation. But at the end of that second year, just on the cusp of my third year, July 1st, I was, I would say that I just finished my intensive care unit block at Toronto Western and University Health Network. I was totally exhausted, had dealt with some very traumatic cases. I was over at UHN and walked by an open door. Inside was one of my mentors. I saw him sitting there and doing some paperwork and I knocked on his door and just impulsively said, “Could I talk to you?” And I went in and I just spontaneously, no planning, poured my heart out. Just said, you know, I'm not even sure I want to keep being a physician, let alone stay in internal medicine. And he was very candid with me in that conversation. First of all, very sympathetic and very compassionate, but also said that he'd had some of those same feelings throughout the course of his professional life. But one of the things he said to me then is, you know, he'd known me since I was a medical student and he'd known that I was a musician and a writer at that time. And he said to me, I just have this feeling that the things that were actually the most interesting about you, you've lost them in the last few years and you need to get them back.

So I did begin doing a little bit more music and doing some of my own writing. I actually went on to pursue music a bit more seriously for a few years after that. But then, as with most of our major learning in our lives, it needs to be repeated. So I think I forgot that lesson because as I journeyed deeper and deeper into my academic career, in my career as an educator, once again, all of those things began to fade away. And I hit a point, I'd say about five or six years ago, where aside from caring for my young children, there was very little in my life except for medicine and in particular, the very meaty academic roles working as an associate dean, which is like being on call for most of the year. And I just had an epiphany one day, almost a kind of took me back to that moment that just my life no longer had much texture. That I really found that work meaningful and it kind of goes back to what I said at the beginning that I didn't feel a low sense of accomplishment. I didn't feel depersonalised at work and within the confined bubble of work. These things were just fine. But when I came home, I just had that feeling like, “Who even am I anymore? What about the rest of me? What about all these other things that were so fundamentally important?” And where the connexion still hadn't been made for me was realising that that part of myself, the writing part and the creative part actually belonged in medicine, that it wasn't like a separate track, right? But actually, there was a way to marry it with my clinical identity. And what's really amazing for me is when those two things came together, when I sort of accepted that they could coexist in my life, that's when my career really took off. That's when my writing started to appear in major newspapers. That's when I sold my book. And so there is, I think, a message there too about accepting who we really are, the things that are really in our hearts and how we can marry them together with our academic careers in sometimes unexpected ways. That's when really wonderful things can happen.

David Gratzer: And the healing also involved some thoughts around changing yourself, and in particular mindfulness, which you've touched on a moment ago. You don't strike me as a mindfulness type of gal and in your book, you talk about that you're the most sceptical person at the mindfulness retreat in the history of mankind.

Jillian Horton: Well, maybe top three.

David Gratzer: Why mindfulness and why did you change your mind?

Jillian Horton: Yeah. What a lovely question. Well, you know, I think I made a mistake that a lot of people make. I think I had fundamentally misunderstood what mindfulness is. I always thought that mindfulness, and this is before I engaged with it really deeply, I thought it had this agenda and I thought the agenda was sort of to brainwash me to turn me into sort of a Pollyanna and to make me somehow say, “Oh, my suffering doesn't matter. Everyone's suffering is important,” and I resented that. And part of why I resented that, honestly, I think, is because I had a lot of unprocessed grief, loss, suffering. And the last thing I wanted was someone to come and say, you know, everybody suffers. It just - that tapped into something so painful within me, a deep unmet need. I guess I felt on some level that many of my experiences in medicine had never been processed, had never been validated. I mean, how could they be validated? We never talk about what it feels like when we lose a patient that we really care about. We never, or I shouldn't say never because I think we're moving towards a healthier culture, but historically we have not really validated the deep, deep loss that we each feel when we go through those things. So I had that suspicion about mindfulness that it wanted to change me, you know, make me less who I was. And I think the other thing that I felt going into mindfulness was that, you know, many of us, of course, as physicians, we know that we tend to share certain traits that are well described in the literature. One of them is perfectionism. Mindfulness is sort of antithetical to perfectionism, right? It's encouraging us to accept the way that things are, and that was a fundamental tension, but also kind of a need for control that many of us carry another trait that's described in the literature. You know, I think we wear that sometimes as a badge, as an identity tag. The late hours that we work, we sort of grimly tell our friends the thing that we did today, the horrible thing that we saw. And there is a way in which we take pride in that our ability to suffer to relay that because that again, is something that is conditioned in us, that we're urged to develop. But maybe there actually is a different way to live. And probably the most important insight was maybe this actually applies to me, really. You know, you hear a lot of things and you go: “Well, that's sort of for somebody else,” or “Yeah, yeah, but my brain doesn't work that way.” It was suddenly realising my brain could work that way. There's this thing called neuroplasticity, and I have it too.

David Gratzer: And you've spoken about yourself, but what should we do differently on a bigger scale? I mean, medical education, how hospitals are organised? What are your thoughts?

Jillian Horton: Well, yeah. So, you know, you’ve tapped into something of course, so important there, David, which is that when we talk about burnout, it's so important for us to communicate consistently that organisational and systemic factors are the primary drivers of burnout, period. They're not my lack of mindfulness, my lack of resilience. As you know, the literature tells us that we have higher levels of resilience than our age-matched controls. And I literally mentioned this almost every time I talk about mindfulness because I know other people know it, but I really need them to know that I know it too, that when I talk about mindfulness, it's not to say, “Wow, just try mindfulness, and that'll make our toxic system go away and it won't bother you anymore.” It will still bother you. It will still continue to damage all of us. But I engage in this work so that I can continue to work within those toxic and dysfunctional systems without sustaining such collateral damage and having my life be so impacted by it. So that's part one, but part two after that caveat, what should we actually do? I mean look at that the Stanford WellMD Model of Professional Fulfillment. I think that's a wonderful way for all of us to begin to think about what we would like it to feel like to work in the systems where we train and go on to spend most of our lives.

And that model, and I'm sure you're familiar with it, has sort of these three components, right? One is the culture of wellness, how we treat each other, whether we have psychological safety, our leaders, whether our leaders lead us with compassion, know us care about us. Another determinant in the literature of whether we are burnt out is the quality of leadership that we that we work for. And then these two other pieces: efficiency of practise, the added cognitive load, all the multiple EMR platforms that we have to work on, the things that drive us all around the bend in our clinical environments, the things that we have to do over and over that seem futile, pointless, that are misaligned with our expertise. So there's that piece we need efficiency of practise. And then finally, there's the piece that mindfulness does work on, although it works indirectly in some ways on those other two aspects as well. But it's the personal resilience piece. So how do we work with our own reactivity? How do we emotionally self-regulate? What have we done to cultivate our resilience? What kind of safety net do we have? What choices do we make to care for our health, physical and mental, when we have the ability to make those choices and exert some control? So I contextualise that because I think when we ask this question, what would we do? What should we do? So for me, what does change need to look like? It needs to look like threefold efforts in each of those domains that are visible that articulated regularly that people understand that if we only improve one of those domains, we won't be creating opportunities for professional fulfilment. It does involve, you know, helping and this is again within medical education, where we have opportunities, really giving people skills, modelling those skills and making sure that the hidden curriculum is aligned with the curriculum that we're actually teaching around, you know, personal self-awareness, emotional intelligence, learning skills that help us with emotional regulation, having structures like the old balance groups and things like that that allow people to focus on processing their emotional experiences

David Gratzer: That's a big agenda. Do you think it's even more urgent now that there's a pandemic and perhaps more burnout than ever before?

Jillian Horton: Absolutely. And you know, I would agree with your assessment. It's interesting because I think we're hearing some early signal coming out of American data, none of which I've seen yet, but suggesting that in some cases there may have been a bit of a paradoxical effect. And again, I don't think we're going to see this as pervasive. I think overall we will see when the numbers roll in and we have time to really assess the state of things. I do agree with you. I think we are going to see that burnout is even more prevalent and that the situation is even worse. But there is again, this phenomenon for some of us that maybe we will actually have reconnected with our meaning and purpose, which of course, is one of the things that has been shown in the literature to give us some immunity against burnout. And so there may be a little bit of an uplift where suddenly we've had a refocus. We are we're sort of connected to what it is that we're here to do. But yes, overall, I think the situation is worse. I worry about a wave of early retirements that's about to hit. I definitely am worried about the burden of PTSD that's going to be there. Folks who during their formative years during clerkship and residency, when their professional identity is consolidating, they've had a lot of really important experiences that have been fundamentally altered in terms of how they relate to patients, the time that they've been able to spend with families, and that's going to have an impact on them.

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David Gratzer: It's a Quick Takes tradition to close with a rapid-fire minute. Shall we put a minute on the clock?

Jillian Horton: Let's go.

David Gratzer: One minute on the clock. Here we go. What's the best feedback you've received from your writing?

Jillian Horton: Stay authentic. Tell the truth. Don't fail the truth as fiction.

David Gratzer: Actor Alan Alda is a fan. Is he actually funny in real life?

Jillian Horton: Oh, he's hilarious, and he's even kinder and more humble and amazing than you would imagine when you have the opportunity to speak to him even better.

David Gratzer: What's your next book about?

Jillian Horton: Hmm. Probably mindfulness. Probably a series of essays that's open on my laptop right now about how we incorporate that work into our daily life, but with my usual sarcastic and occasionally expletive laden voice.

David Gratzer: Do you enjoy practise right now?

Jillian Horton: I love practise. I love it, and it's my respite during the day. I think through doing that work, I've boosted my vagal tone and so I continue to accrue more and more benefits of it through neuroplasticity and that mechanism.

David Gratzer: And at the buzzer, one last question you've mentioned the importance of emotional intelligence and true leadership. When are you running for office?

Jillian Horton: Absolutely never. However, I am willing to write speeches for anybody that I believe in, and there are a couple of people that I've already offered to do that for.

David Gratzer: Dr. Horton, your book is terrific, We Are All Perfectly Fine. And you've given us a lot to think about. I knew that at one point in the book, you talk about how you'd received a full scholarship to Oxford and thought about pursuing a PhD in English and instead chose a medical career. We appreciate that you've done just that.

Jillian Horton: Well, thank you, David, and I just want to say, you know, I write a lot about the downsides of medicine. But the flip side is it is a privilege to be part of this community, the brother and sisterhood of medicine. I feel it, and I've never felt it more than since I released this book, and it's been received in this way. I'm just constantly grateful for that privilege and to my amazing colleagues and to you for this beautiful conversation. Thank you.

David Gratzer: Thank you. Dr. Horton.

And that's this episode of Quick Takes.

[Outro: Quick Takes is a production of the Center for Addiction and Mental Health. You can find links to the relevant content mentioned in the show and accessible transcripts of all the episodes we produce online at porticonetwork.ca/web/podcasts. If you like what we're doing here, please subscribe.

Until next time.

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