That Old Familiar Feeling

What is the Colour When Black is Burned? -Neil Young

I have been quite burnt out over the last fives years. No, it’s been longer. My burnout culminated in 2019 and 2020 with serious effects on my well being and mental health. My first inclination is to say that the feeling of burn out is hard to recall, but really, it is an old familiar feeling. It will not leave me alone, or is it the other way around?

What is ‘burn out?’ I think we all experience burn out to some degree or another- due to stress and circumstances that are both in and not in our control. It is something that is easier to spot in someone else; self reflection isn’t enough. Burnout is something you can see in somebody, if you know what it looks like, it is very common, and we rarely have clear insight into our own burnout.

Burnout can be defined as “physical or mental collapse caused by overwork and stress.” This is all too common amongst physicians. Family physicians in particular have been shouldering the weight of our population’s health needs for decades. For years our public healthcare system has been under strain, and this is well understood. Our population has been aging, disease management is more complex, there are higher rates of cancer and chronic disease. There is also a mental health crisis. While our needs have been compounding seemingly exponentially, our resources and ability to treat and manage these issues has been faltering. I have seen wait times for surgery, imaging, and specialist consults become so long that it is almost silly to make a referral for a patient.

I would argue that our medical system reached a breaking point when COVID reared its ugly head. COVID required us to close our practices and not have any physical contact with patients. It was like we were driving 100km/hr and had to stop because the freeway suddenly turned into a nasty pothole ridden back road. In some ways COVID was a blessing in disguise, I say that because it actually forced me to slow down, which in retrospect was sorely needed.

In the time leading up to COVID, I was very busy. I was seeing at least 50 patients daily, often more. I divided my time between family practice and hemorrhoid treatment in Vancouver. When you see that many patients per day, there is a high administrative burden. This comes in the form of paperwork and reviewing laboratory tests (up to hundreds a day). There is also other administrative issues that aren’t as common, but do crop up; and when they do, you’d better hold on tight and hope you have your wits about you.

I won’t get into deep details as I am drawing on the experiences that I have had with real people that I care for. I’ll share a few of the stories that I think led to my burnout. In fact, burnout nearly made me leave medicine, and it almost killed me.

When I first hung my shingle, in 2011, I took over a practice that was set up to attach people without a family doctor to nurse practitioners. Many of these patients had addiction and mental health issues. It was a great opportunity for me to take over a practice that was in its infancy. It gave me the chance to build my practice by accepting new patients; I built up the practice to about 1500 patients. I’m grateful that I did take over that practice as it taught me a lot about medicine and running a practice. I’ll share a few stories from the front lines of family medicine.

I’ll never forget this single mother and her son. The mother had a long history of anxiety, depression, and chronic pain. When I met her, she was taking amitriptyline for depression, insomnia, and chronic pain. She complained of chronic pain in her knees with no history of trauma, arthritis, or surgery. Her x-rays were normal, the MRIs of her knees weren’t convincing for any major abnormality. She had seen multiple orthopedic surgeons, physiatrists, and neurologists, all with the same diagnosis, chronic pain. She had also been to psychiatrists a handful of times for her depression and anxiety. She had tried many antidepressant medications and did not have a psychiatrist that would see her on a regular basis. This is a story that I have seen multiple times in different patients over the years. There is a large population of people with chronic pain and mental illness that just exist in our society. It is a huge problem, and family doctors are the ones taking care of the majority of this population.

The problem with this young single mother was that she had been on oxycodone for years due to her chronic pain. I can’t recall her dose exactly, but I want to say that she was taking at least 20mg twice a day, which is equivalent to about 120mg of morphine per day. Her son was maybe 4 years old at the time. I managed her for a year or two, that included prescribing her oxycodone as she was dependent on it. One morning at the office, I got a call from the coroner (my first). It turned out that this mom had overdosed on very large doses of amitriptyline and oxycodone based on the post-mortem toxicology. This event had occurred a few days before the coroner actually called me. The coroner told me that only the mother and her son were at home when the overdose occurred. The patient’s mother went to check on her after not hearing from her for a few days. The little boy had been with his deceased mother for that entire time and had set up his fire truck and police car toys around her body and was playing the sirens over and over again trying to wake her up. Truly horrific and heartbreaking. That little boy went to live in Alberta with his aunt and grandmother.

Unfortunately, I would receive similar calls from the coroner over the years about patients that had overdosed on opioid narcotics. This was the beginning of the opioid crisis, and fentanyl was starting to make its way into the drug supply on the streets. I think we are all too familiar with this topic in 2023.

More recently, in 2018, I was chosen for a mandatory chart audit from the College of Physicians and Surgeons. The college is a entity that governs the professional and medical conduct of physicians and advocates for patient care. Every so often the college will invade a practice and audit the charts of patients and poll patients asking about how satisfied they are with their care.

I was audited, so that meant paperwork and meetings on top of my busy schedule. The college also audited my patient panel for prescriptions of controlled substances, such as opioids (morphine, oxycodone etc) and benzodiazepines (ativan, clonazepam). These are potential drugs of abuse and we as prescribers are tasked with the responsibility of overseeing the proper use of these medications for patients with chronic pain, post-operative pain, cancer, or mental health issues.

By the way, the college has the power to look up prescriptions for any person in British Columbia, without consent. Family doctors are tasked with overseeing the prescription and management of these drugs. Why? Good question, it’s because nobody is else is willing to as it is ‘out of their scope of practice.’

The college review process was so inefficient and took so much of my time, the reviewers were not fair and actually I don’t think they had practiced medicine in quite sometime. Needless to say it was an un-needed stress. That process started in 2018, and due to the slow moving, grinding bureaucracy, it took until 2020 to complete. Guess what? I have just started another round of the same process in 2023. Maybe I’ll get through it by 2030.

In 2019 ,about the same time as this audit, I had a patient from the hemorrhoid clinic I work at get diagnosed with colon cancer after having a colonoscopy. I have found many early stage rectal, colon, and anal cancers over the years, however, I can’t find them all. The cancer was high in the colon, where I would not be able to see it with my proctoscope. A gastroenterologist called me and said the cancer was well into the sigmoid colon. Long story short, this starts a long process of letter writing and lawyer consults and phone calls- all on top of my busy schedule. I would book my phone calls after a day of seeing sixty patients from 8am to 5pm with no breaks. It goes without saying that I feel the most concern for the patient that has to deal with this potentially fatal disease; unfortunately, in reality, as a physician things like this happen.

Later that year, a radiologist’s office failed to send a report that gave a cancer diagnosis for one of my patients; the radiologist made a complaint to the college accusing me of neglect in diagnosing this cancer. This person probably got freaked out that his office screwed up and went running to the college before anybody else did. I think this guy could give a masterclass on diversion and gaslighting. Anyway, this led to more letters, phone calls, lawyers, and stress.

Keep in mind I am the person that is responsible for the ongoing care and management of these unfortunate patients that still require care. I take the time to sit down with the patient and their family to discuss every aspect of their care without a time limit (in a medical system that does not reward extra time for patients). I do this while juggling all of my clinical and administrative responsibilities. I have to deal with the administrative aspects of this medical complaint while taking care of the patient and their family. If you have been in these shoes, you will know how difficult, stressful, and rewarding this can be.

In the same year, a family with three kids I had been caring for several years was having a crisis. The father had become very depressed and became suicidal after leaving his job due to injuries from a car accident. One day while counselling this patient he disclosed to me that he was seriously thinking about killing his family. He calmly explained that he had thoughts of strangling his children and killing his wife, then himself. It had been a real struggle to get him mental health support. No psychiatrists were taking patients ( very few are these days) I was dumbfounded about what to do for this family and I was genuinely worried about those children. So I took time to look into the legality of the issue, calling the CMPA- The Canadian Medical Protection Agency (doctor’s legal representation in Ottawa), and continuing to work my same hours. Thankfully, I was able to stabilize the patient with medications and counselling and find him an excellent psychiatrist. Nobody was harmed. There was little direction given to me from the CMPA, it turns out that there is not much one can do when such threats are made. Since my clinic days are so busy, I was calling the CMPA in Ottawa early in the morning and often while I was driving to my clinic in Vancouver. One physician advisor at CMPA had little advice to give me other than saying that family medicine was a very difficult job and she was thankful that she had switched her career over to respirology years ago.

Needless to say I was in perfect mental shape going through all of this stress.

Truthfully, I had anxiety. I had a perpetual feeling of doom and that something bad was going to happen at anytime. It was very uncomfortable and I tried to ignore it for a year or so. Ultimately the anxiety turned into depression. I felt like I was emotionally in a very deep hole, hopeless and alone. The feeling of being alone was very overwhelming and I was isolating myself from my family. I did not have any friends or family nearby, I was a hermit. The most difficult times for me were weekends. When there was no work I felt immediately like I had no purpose and I started telling myself that I should just check out. I continued on for a long time, just getting by, my home life suffered greatly. I started having dark, desperate thoughts; I was so exhausted and felt hopeless.

Ironically, I approached the College of Physicians and Surgeons as they have some kind of ‘outreach’ program for doctors in crisis. I had to reach out to them because their audit of my practice was occurring during this time and I needed an extension of their deadline. I had a zoom consult with a cold psychiatrist that works for the college. It was funny because I could tell that she was simply screening me for signs and symptoms of psychosis or addiction. She was also probing into my family life, which I thought was strange. When she found no evidence that I was completely off the reservation, she was content to have me go on my way. I asked her, what do I do about my income if I have to slow down or stop working? Her answer was that I’d have to live with that decision despite my high business costs and the fact that I have dependents. I do have disability insurance and I pay very high monthly premiums for this. I found out that there was a clause put in place by my insurer that they would not cover me for any mental health related absence from work. It turns out that they somehow found out I had anxiety and made that clause when I had renewed my policy a year or two before. So, I kept working so I could pay my mortgage and put food on the table. This couldn’t have happened at a worse time; I really needed to take some time off to catch my breath and rest; I don’t have sick time, or a union, I just have my patients. If I do not work, I do not get paid. Sounds fair right? My disability insurance program is offered from the Doctors of BC, my ‘advocacy’ group.

Along came COVID and I was forced to slow down. This gave me a chance to recuperate and take care of my mental health. These days, I have to be honest and say that I have that old familiar feeling lurking again. Thankfully I am in between crises now, things are pretty stable in my world. I am working just as much as I did pre-COVID and the college is starting another audit of my practice. Will I survive the next meat grinder I am tossed into? Time will tell I suppose.

My experience is not unique among family doctors. It is a difficult job, rewarding and important, but difficult. I want you to know what happens behind the scenes in a family practice as we are all in a healthcare crisis in Canada. Have you been waiting for years to see a specialist for an operation? Have you seen a loved one get diagnosed with cancer and have to wait months just to speak to an oncologist? If you are lucky enough to have a family doctor, do you wait an hour or or more to see them in clinic? Does your family doctor limit your complaints they can entertain? These are all symptoms of our failing medical system. Doctor’s are struggling too in many ways, I hope to shed more light on this and offer suggestions for solutions to these problems.

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Toma