AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.
Featured topic and speakers
In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger talks with Jillian Horton, MD, associate chair of the internal medicine department at the University of Manitoba Max Rady College of Medicine, in Winnipeg, Canada, about how physicians can help leaders address the complicated issue of physician burnout by sharing their stories. Dr. Horton is also the author of the national bestseller: We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing.
Learn more about mindful practice in medicine.
Speaker
- Jillian Horton, MD, associate chair, internal medicine department, University of Manitoba Max Rady College of Medicine
Transcript
Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're joined by Dr. Jillian Horton, associate chair of the internal medicine department at the University of Manitoba Max Rady College of Medicine in Winnipeg, Canada, and author of the national bestseller, We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing.
Dr. Horton will share with us how physicians are sharing their stories and how that helps them address complicated issues around physician burnout. I'm Todd Unger, AMA's chief experience officer in Chicago.
Dr. Horton, thanks so much for joining us today. I know this issue is very personal to you and I thought we could just start out having you share your own personal story of burnout and what ultimately helped you.
Dr. Horton: Thank you so much for having me, Todd. It really is lovely to be here with you today. So, I came to a realization about five years ago that I was at a point in my career that unless something changed, I was going to have difficulty continuing to practice medicine. It was a slow realization because when I look back I think for many years I had actually been cycling in and out of burnout. I never recognized it or labeled it as such because my patient care never really seemed to be affected and the way that I related to patients or felt or engaged at work never seemed to be affected.
But when I got home at the end of the day, there was nothing left of me for my kids, for my spouse, for my family, my extended family, and my friends. As a result of that realization or around the same time as this had begun to dawn on me, I traveled down to a program at the University of Rochester where the Mindful Practice program originated, invented and created rather by Ron Epstein and Mick Krasner, and that put me on a very different path. Skills that I continue to apply today and changed the way that I see and approach burnout, both as a clinician and an academic but also as a human being.
Unger: I'm a meditator myself. I found it to be very helpful in my life and I think mindfulness is an extremely powerful tool. What's interesting to me is how did you get to this idea about storytelling? Because that's a different thing. When did you find out that this was really powerful for you?
Dr. Horton: Yeah. What's really interesting, Todd, is the Mindful Practice program utilizes a lot of storytelling, a lot of roots of narrative medicine, shared stories, connecting with peers over important events in our life. Sometimes events that have occurred in our careers that we've never resolved. There's a heavy emphasis on telling our stories in ways that allows us to see ourselves from sort of a strength-based or asset-based approach as many would call it using appreciative inquiry. Then also trying to divine through our stories and reflecting on our experiences, what do we find the most meaningful? Where did we derive meaning? What was the meaning in our suffering?
I think I've always been a writer. I was an aspiring writer for many years before I published this book and I think it's no mistake, sort of no fluke that just at the time this work came into my life and transformed it, that I really found my voice as a storyteller because a lot of those skills, the emotional processing, the consolidation, they all turned out to be related and also related to being more mindful.
Unger: How does that then bring about change? How have you experienced that?
Dr. Horton: Yeah. Well, one of the things, just to talk about meditation for a few minutes. I mean, many of us will be familiar with the physiologic origins of how meditation helps us. One of the things we're doing is hacking our vagal nerve and we know that we see associated functional MRI changes when we have been meditating for a long time. Thickening of our prefrontal cortex, shrinking of our amygdala, improving our sort of emotional consolidation and self-awareness. All those things are rooted in the literature.
But one of the things that I found is that meditating ... I would like to think that most people that I work with would experience me as a person that they would describe as nice or kind. I think this work by modulating my reactivity, and we do know from the literature as well that mindfulness practices and meditating can increase our agreeability, our benevolence but certainly it influenced all those things at work.
I just became outwardly as well as inwardly a calmer person, a person whose periods of reactivity or expressions of stress and irritation I think would attenuate much more quickly but I also developed more of a sense of just being present in my own life. I always thought I was pretty present with my patients and I think most of them would still describe me as that in that way but qualitatively something changed.
I began to experience that in a much more profound way, that the presence itself began to seem not just like something that I did or that was an aspect of my clinical identity but also that it was something quite fundamental to my most intimate identity as a clinician, that it was a tool and an aspect of my clinical identity that just began to feel totally different.
I think anyone who's done this kind of work knows exactly what I'm talking about. You sort of sink into yourself and there's a moment when, instead of thinking about everything else ahead of you, all the stresses, the pressures, you're just there, you're just with the person and that is very satisfying.
Unger: Well, let's talk a little bit about, obviously the last two years have thrown a wrench into a lot of things with the pandemic, and like many things, we've seen the issue of physician burnout increase with the pandemic. Again, something that was already there made worse. Has this kind of storytelling become even more important in the last two years?
Dr. Horton: So, I think we've seen a few really interesting trends with physician narratives and actually all health care provider narratives during the pandemic. One is those kind of frontline eyewitness stories, not just about what we're seeing and experiencing but also what is it like to be that person, to be health care workers on the front lines. We've seen a really profound interest in the media in hearing those stories and I think it's broken to some degree a psychological barrier.
I would imagine for many of your listeners, there might be a similarity that we share, which is before about 14 months ago, I had never spoken to the media about anything to do with health care. I'd talked a little bit about my writing, I'd written some op-eds but I had never had a conversation with a reporter or a national news anchor about what was happening in my life as a clinician or our life in the hospital.
So I think something important, sort of a psychological barrier for many of us has been broken but I also think leading up until this time, we have been seeing a shift. Certainly for years, we've been seeing stories about burnout in hospital. So many of your American physicians, Dr. Sinsky, Dr. Shanafelt, so many others leading this work but what I viscerally sense is we've had gone a little bit from headlines about the story and the problem of physician burnout to really personal stories.
I think of the story of Dr. Lorna Breen as being a very fundamental shift. We sort of went from hearing about the crisis of physician suicide, to hearing about a person, an individual whose name has become synonymous with paying the ultimate price for the loss of one's mental health in medicine.
I think the more individuals, and tragically, I mean, I wish no individual name had to be associated with this story but the more individuals become associated with these narratives, the more it allows the public to really begin to understand the human cost to relate to us, to take the story from concept to something very personal that generates empathy in them. Then people can begin to align with us to try to address some of the really challenging circumstances in medicine that so often pose a threat to our mental health, our well-being and our ability to care for others.
Unger: We've had a couple of episodes over the last two years about Dr. Breen and with folks from the Breen Foundation and I know that part of that is an encouragement of physicians to speak out and speak up and not to be afraid to do that. I'm curious, in your recommendations, where is the storytelling occurring and who's listening to it?
Dr. Horton: Great questions. So, sometimes storytelling is occurring informally. People at department meetings, residents, trainees in forums, they're at retreats and they're telling about their experiences and sharing those things, and informal storytelling is important. But I think one of the single most important things we can do and particularly, as we become more senior and more visible in our leadership roles, we can very intentionally choose where we tell stories.
We have to do that with what is called in the business literature selective vulnerability. So, we really have to think about if I get up on that stage and tell a story about my own burnout, or perhaps for someone else it's a story about their mental illness or a struggle with some difficult aspect of being a physician, would it have helped me to have heard this story from someone else? Would it help me now?
This is one of the really important questions I think we can ask ourselves because sometimes we can venture into oversharing that isn't well thought out. Again, to be really clear, I don't mean people shouldn't say whatever they—
Unger: I notice selective, selective vulnerability.
Dr. Horton: Selective, that's right. So, really considering is this just catharsis, a download of trauma or is this intentionally placed and still raw, still honest, still authentic but put out there for a reason, to help, to be of service to someone else and not just me in the tongue, even though that is often a valuable byproduct.
So really thinking about where and the why, but then seeing if we can find that courage to be vulnerable and step onto those large stages at conferences, at events, in media to tell our stories, knowing hopefully that they will humanize our profession for other people and that those who have gone through some of those experiences that we know are very, very common in medical training, our traumas, our losses, sometimes our private struggles with mental health. The more we can put those onto large stages where those stories will reach the largest audiences, the more powerful their impact will be.
Unger: Well, you mentioned Dr. Christine Sinsky is leading a lot of the work on burnout, physician wellness at the AMA, and of course I've learned through talking with her and the research they've done is that burnout is a system level issue that needs to be addressed in that way. When you're thinking about the intersection of that learning and your work, what can health care leaders do to build a culture that makes it easier for physicians to open up in this way and help each other?
Dr. Horton: Well, one thing I just want to say, and I'm such a fan of Dr. Sinsky and her work, she's had such a profound impact on so many of our careers and the way that we conceive of so many fundamental issues within physician wellness but one important thing I would say to many health care leaders, keep your hands on the right domains.
So when we think of the Stanford Model for physician fulfillment, professional fulfillment, as you say, the issues are predominantly system issues. About 80% of the problem traces back to system issues, culture of wellness and efficiency of practice. But what we often see is a pattern where organizations try to kind of put their hand into the personal resilience third of that wheel, which really is called personal resilience for a reason, because it belongs to us.
I just think it's a really important distinction because when it comes to mindfulness, I always ground. Anytime I'm going to talk to a group about mindfulness or do work around mindfulness, I'm very intentional with how I'm framing it. I say, "I share this with you person to person. I don't share this with you as a solution for the massive system problems that our organizations need to address. This doesn't belong to them, this belongs to us and to me. You and I do this work to fortify myself, so I can continue to work within a toxic broken system for long enough to make it better for the next generation."
So that's one piece but the second piece, what can leaders do? Of course we know that authentic, compassionate leadership is a critical determinant of what it feels like and what it is like to work in a particular environment, what the culture is like. Do our leaders care about us? Do they know us? Do we feel seen by them and protected by them? And is psychological safety offered?
So all those things kind of go without saying but I think as it applies to storytelling, just to hone in on that for a minute, I think it is so powerful when leaders of organizations tell authentic stories that make them appear as vulnerable and as human as the rest of us. I think right now we know that organizations where leaders are acknowledging their limitations, talking about what the unknowns are, what they are struggling with, what they are worried about, as opposed to simply being prescriptive, as opposed to this one is really insundry, just saying, "Be kind to everyone."
I've written a bit about the kindness. Gaslighting, where we just sort of pave over all the complex difficult emotions that people have and just give this platitude. Really avoiding doing those kinds of things and just trying to be there in the now with your people, asking what they need, how this has affected them and what you can provide to make things better.
It does also trace back to mindfulness in a sense, it's that sort of curiosity. It's noticing, it's embracing uncertainty, knowing that we can't mitigate it or obliterate it, it's just a part of our experience right now. I think those kinds of mindset pieces are so critical for leaders getting their people through these times, because of course we have a really long road ahead of us.
Unger: We've said that physicians need to be willing to rewrite their ending. What do you mean by that?
Dr. Horton: Yeah. So, when we look at stories that many of our senior leaders often tell us about their medical training, what do we often hear? We hear, "Well, you know what? I worked 100 work weeks for four years but it made me better," or "I was a young junior surgical resident and this person used to throw instruments at me and it toughened me up."
There's this concept called narrative fallacy, which many of your listeners may be familiar with. It's a term coined by Nassim Taleb. The idea is that when we look back at events that have occurred, our minds are really good at creating stories. We don't see things in sort of a disconnected, random fashion, we try to create something linear from point A to point B. Sometimes because we survived traumatic or difficult events, we make a fundamental attribution error. We say, "Well, those events helped me get to point B."
It can be very difficult because often that is how we created a narrative that allowed us to survive. That allowed us to survive difficult, traumatic experiences, having things thrown at us, working beyond any physiologic limitation that any living human has. So, I think it can be very difficult and painful actually for us to look back and say, "You know what? That actually probably didn't help me. There's probably a whole other version of myself that didn't live through those experiences that might have been much better if not for them. I did survive but I'm going to be willing to create a new story about them that perhaps will allow me to see the next generation's experience differently, to respond to their needs differently and to be part of this movement of making meaningful change in medical culture."
Unger: Well, Dr. Horton, thank you so much for being with us today. I feel better just talking to you, so thank you for the advice. If someone was to find out more about this, where would they look?
Dr. Horton: Yeah, so the Mindful Practice program at the University of Rochester, if you just Google that, lots of great resources on a Mindful Practice landing page there, including how to take the courses. In particular, the course that I took that had initiated such an important series of events in my own life. I write about that course in my book, which is called, We Are All Perfectly Fine and that book is available from all major online book sellers in the United States and is published by Harper Collins.
Unger: Everybody, take a look. Again, thanks Dr. Horton. That's it for today's Moving Medicine video and podcast, we'll be back with another segment soon. Remember to click subscribe on AMA's YouTube channel or wherever you listen to your podcasts. You can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us, please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
