New Normal: How Healthcare Systems Impact Practitioner Distress, with Dr. Martin A. Koyle (Read Transcript)

New Normal podcast, April 14, 2022, hosted by Dave Kaufman: New Normal: How Healthcare Systems Impact Practitioner Distress, with Dr. Martin A. Koyle
Dave Kaufman – host: “Primum non nocere.” First do no harm. There may be no more essential part of the Hippocratic oath than this. When you visit your doctor, do you take for granted that they will do no harm? What if our health system is preventing doctors from giving you their best? What do we do when the greatest thought leaders we have say that they simply can’t do it anymore, that the system they’re navigating is exhausting, subpar, and leaving them with one hand tied behind their backs? And what if all these problems predate COVID? There’s a way out, but it isn’t easy. Let’s find out how.
Dave Kaufman – host: Welcome to the second season of the New Normal, the podcast exploring management research brought to you by Delve, the official thought leadership platform of McGill University’s Desautels Faculty of Management. I’m your host, Dave Kaufman. On this episode of the New Normal, we will discuss how the Canadian healthcare system hinders the success of medical practitioners, explore the extreme mental duress that doctors, nurses, residents, and others in the system face while doing their jobs all while the COVID-19 pandemic has made all of these problems more acute. Finally, we will look at what is being done to break the stigma and give those in the medical system the best opportunity to do no harm to their patients or themselves.
Dave Kaufman – host: Joining me for this episode is Dr. Martin Koyle, Professor Emeritus of surgery at the University of Toronto, where he held the chair in pediatric urology and regenerative medicine whilst serving as the division head of the pediatric urology unit at the Toronto Hospital for Sick Children. He’s also a faculty member at the Desautels Faculty of Management at McGill, where he is actively involved in the International Masters in Health Leadership and the graduate certificate in healthcare management programs. He completed the International Masters in Health Leadership at McGill in 2021. After an illustrious 30 plus year career in the United States, Dr. Koyle returned to Toronto Sick Kids Hospital in 2011. He realized pretty quickly that the Canadian healthcare system was not as robust as he had once thought and that coming back from America would have certain challenges.
Dr. Martin A. Koyle: When I left Canada in 1976, I had this idealistic vision of what the Canadian healthcare system was and was totally supportive of the concept of a single payer system. It was interesting that after spending the bulk of my career in the US, both in post-medical school education and in the practice of medicine, that I came back 35 years later and it was as if nothing had changed. I was totally shocked. Medicine seemed to be so progressive in the US, and it was almost like a time warp when I came back to Canada.
Dave Kaufman – host: I asked him to elaborate.
Dr. Martin A. Koyle: I think a lot of it has to do with resources and culture in general. And I’m not saying that it means that it’s bad, but it certainly wasn’t to what I had expected from a communication, collaboration, teamwork perspective, and certainly from an organizational and technological perspective. I was salaried no different than I was at Sick Kids. So there was no great incentive for me to produce more. On the other hand, I knew I had to provide a service that was as good if not better than the competitors in the regions that I practice if I wanted to maintain a practice and to strive for excellence and to promote the academic growth of my department as well. So there’s an ego part involved with it more than fiscal for me in that I was striving for excellence and I wanted to build something that was better than the current situation was.
Dave Kaufman – host: I asked Dr. Koyle to tell me a little bit about the differences between the patient-doctor experience in the States versus that in Canada.
Dr. Martin A. Koyle: So it’s very different in the states in that every patient I saw throughout my career in practice was my patient, in that I would see them personally, I would make a decision with them and regarding their subsequent care and follow-up. And I used the resources around me, for instance, allied health providers, nurse practitioners, and physician’s assistants as team players in the care of that patient. When I came to Canada, the system was totally different in that it was almost like an assembly line. There were so many patients that had to be seen and they couldn’t all be seen by me. So as a result, many, many of the patients never met me. I often was double and triple booked, which would never happen in my practice in the US and I felt I was delivering substandard care as result, that I was juggling so many balls that there was no personal relationship with the patients.
Dave Kaufman – host: Dr. Koyle’s return to Canada was fraught with challenges. First, he was navigating a health system that he felt was antiquated. Second, he described himself as having a feeling of intense dissatisfaction with his role in the profession.
Dr. Martin A. Koyle: I felt that I was so distanced that absolutely I wasn’t feeling the same as I did in the United States. And to me, wellness has multiple definitions, but it basically was looking at life and your career in a positive manner and feeling good about what you did. And I wasn’t feeling that way to be quite frank with you.
Dave Kaufman – host: So unlike many who endured trauma quietly and alone, Dr. Koyle has decided that in order to improve things for him and his colleagues, he’s opening up to talk about many of the personal issues that he has faced. He’s also based his scholastic research at McGill on this very subject. He’s turning his own experience into advocating for healthcare systems where physicians are leaders and the overall mental and physical health of healthcare workers incorporated into everyday organizational practices. The goal of these changes is to increase the safety of the system and reduce harm to patients. Dr. Koyle mentioned second victim syndrome, a phenomenon when a medical practitioner experiences emotional trauma as a result of having a role in a harmful patient safety incident as an issue that especially needs wider attention.
Dr. Martin A. Koyle: I think that we’ve basically been told that we should suffer in silence. That’s the way we’ve learned and we’ve learned from our culture. It doesn’t mean it’s right and it doesn’t mean it shouldn’t change. And there’s many, many scenarios that we’ve learned from including the second victim and moral distress where peer support might be very helpful, especially early on when resilience has been overcome or a catastrophic event has occurred.
Dave Kaufman – host: So are we starting to see that change? Is peer support something that’s becoming more acceptable in the medical world?
Dr. Martin A. Koyle: So I was quite impressed that Sick Kids in the last three years developed a peer support team. They were well trained peers. It doesn’t mean that a urologist would see a urologist or a nurse would deal with a nurse, but individuals were trained to be active listeners, meaning that they could listen, not make the person who was involved with the incident relive the event, but rather just hopefully speak their mind, relay it to somebody who is interested and cared about them.
Dave Kaufman – host: Initially, when Dr. Koyle started his masters at McGill, his plan was to look at policy position with respect to moral distress, moral injury, and healthcare workers. However COVID occurred and if anything, it accentuated his focus and increased his desire to find a way for those in his field to get help when they need it.
Dr. Martin A. Koyle: I also had a position where I was teaching at the Institute of Health Policy Management and Evaluation at the University of Toronto and had medical students, residents, and fellows who were under my academic care. And I thought it would be interesting to look at moral distress in them but I also wanted to look at other issues related to wellness and how might I best instruct them in a virtual environment since we would no longer be able to teach in person. So I put together, with some colleagues, a PowerPoint presentation related to wellness, which went over some of the things we’ve discussed today, burnout, second victim syndrome, issues that might cause them, that might remedy them, the importance of resilience, peer support, openness, et cetera. And by putting together this PowerPoint, it was associated with the pre and post test to see what was their appreciation and knowledge of issues that were associated with wellness.
Dr. Martin A. Koyle: And the end result was it was very well received by this group. So we took it to a second group of learners that happened to be residents in the Department of Urology at the University of Toronto. And we had similar results in both groups in that there was little knowledge or recognition of the importance of some of the root causes that were related to burnout, such as moral injury or second victim syndrome, malpractice, something we haven’t talked about, the imposter syndrome, and how important they are to be recognized and what resources there are beyond resilience that might be impactful and important in mitigating burnout and being unwell within medical school, or ultimately as a postgraduate physician and certainly as a practicing physician thereafter.
Dave Kaufman – host: Dr. Koyle says that a significant number of his colleagues are suffering and they’re doing so alone. As we know, doctors are notoriously bad patients, but by not taking care of themselves, they’re increasing the risk of harming not just themselves, but also their patients. He says that the key to being a good doctor is not just drive or intelligence or compassion, but also about his or her ability to navigate a complex system that isn’t necessarily set up for them to succeed.
Dr. Martin A. Koyle: So it gets back to the whole issue beyond resilience is how do we impact the systems in which we work? And that really depends on us developing physicians as leaders. And by that, I mean is that we live within systems and there’s person by the name of Demings, who is the father of what we call process improvement today. And he stated that every system is perfectly designed to get the results it gets. And what’s happening today is that we’re seeing a situation, there’s a lot of management of medicine, but there’s very few physicians who actually become leaders. And there’s a distinction between the two. And why is this important? Well, I’ll get into it in a second but I think today we look at medicine in terms of quality and the value that we’re providing and much of it is based on what the Institute of Healthcare Improvement has called the Triple Aim.
Dave Kaufman – host: What is the Triple Aim?
Dr. Martin A. Koyle: The Triple Aim is responsive to population health, per capita cost, and the experience of care. What was lacking in that however, was it didn’t really look at who’s providing the care and what’s the wellbeing of those who are involved in actually taking care of the patient. So what’s happened is that medicine, whether it’s Canada or the United States, has tried to emulate what we term a highly reliable organization, similar to the military, the nuclear industry, the flight industry and a lot of that is based on how do we realize that humans are humans and we make errors. What we want to do is we want to develop a system where we can devise barriers that reduce the harm to a patient that we as individuals are apt to cause. James Reason suggested something called the Swiss cheese model, where despite setting up many barriers, occasionally like Swiss cheese, the holes align with one another and what ends up occurring is the patient is still harmed, but that still should allow us to build a better mouse trap.
Dr. Martin A. Koyle: What’s important within the context of this highly reliable organization is something called the just culture where it’s an open and fair environment where we learn from our mistakes and learn from others, where we design safe systems, and where we manage our behavioral choices. And this was all based on a publication by the Institute of Medicine in 1999, called To Err is Human. It was thought that we as healthcare providers probably lead to the unplanned death of close to a hundred thousand people in the US.
Dave Kaufman – host: Per capita, that would mean approximately 10,000 deaths in Canada. Although based on Dr. Koyle’s earlier comments about the inadequacy of the Canadian healthcare system, one could posit that that number would be even higher.
Dr. Martin A. Koyle: That was 1999. 10 years later, Lucian Leape who’s a professor at Harvard School of Public Health and was a pediatric surgeon, in front of Congress stated that the single greatest impediment to error prevention in medical industry is that we punish people for making mistakes and that’s still what we see in healthcare. We see a lot of finger-pointing. As a matter of fact, a study was done which showed that 90% of people in healthcare admitted to having been involved in a serious safety event or medical error, but 90% of the time there was no support from the healthcare organization. So my biggest plea would be that we as healthcare providers, we as leaders in our professions, really advocate for openness and for the reality that humans are fallible and that we need to create better systems for the patient and to protect those who provide the care for those patients.
Dave Kaufman – host: When COVID hit, we started to hear much more in the media about healthcare practitioners and their experiences with burnout. Yet it sounds like burnout has been going on for decades and has much more to do with how healthcare systems are managed. What does burnout really look like to healthcare practitioners working in a system that isn’t set up to fully support them?
Dr. Martin A. Koyle: Well, I think burnout is something that has become so generalized now that it’s become a colloquialism. It doesn’t mean that it’s not important, but many of the other issues are co-mingled with burnout. And I think generally when we define burnout, it’s a feeling of being over-extended and really depleted of your own emotional and physical resources and responses. But if we look at issues that are related to burnout and mental wellness, the other key maladies that can occur are depression and most importantly suicidal ideation and even frank suicide. I think what’s very resounding is a CMA survey from 2017 that looked at practitioners in Canada, but specifically also focused on residents, so physicians in training, and the results with the residents were much, much worse than they were in the general physician population, in that burnout was found in 38% of them, depression close to 50%, and 15% had suicidal ideation. Importantly, if we look at those components, burnout, depression, and suicidal ideation, they’ve generally been shown to be associated with making medical errors.
Dave Kaufman – host: So in fact, it is so much more than burnout. Medical practitioners are suffering from serious mental issues. Their mistakes are impacting not just their lives, but those of their patients as well.
Dr. Martin A. Koyle: Remember that the signature saying for physicians is, “Primum non nocere,” which is first do no harm.
Dave Kaufman – host: First, do no harm to your patients and to yourselves. The hours, the pressure, the life or death nature of the job, Dr. Koyle says that in spite of these stressors, doctors still consider their careers a calling, and there are no shortages of applications at medical schools. As he mentioned earlier, residents and doctors in training suffer from higher than average odds of burnout and other mental illnesses related to work. So I wondered how he counsels students or young doctors entering the field to prepare themselves for the stressors that will affect them.
Dr. Martin A. Koyle: So that’s a real key question because it’s been shown that medical students, when they matriculate into medical school, actually function at a very high level compared to age match controls in university environments. However, when you look at the components that I spoke to you about before, burnout, depression, and suicidal ideation, by the time they finish medical school, they’re far worse than those other controls, so the ones who didn’t go to medical school. And the question becomes what happens during medical school? Is it because these are the people we’re choosing who are all competitive people coming into medicine, medicine is a grind, they have other issues in life that they’re trying to deal with, whether it’s family, deciding on what they’re going to do after medicine, and competing yet again for the best sub-internships and ultimately the best letters of recommendation to get into a competitive residency and ultimately career? So there’s certain stressors that are very unique to the residents and young physicians in training that overcome their resilience.
Dave Kaufman – host: One of the expectations that a doctor has to deal with from the outset of school is the realization that they will work long and difficult hours. Dr. Koyle tells me that residents are told to be ready to work 110 to 120 hour weeks. I questioned whether these hours are a factor that lead to the struggle that doctors face today.
Dr. Martin A. Koyle: Certainly, but I think there were certain expectations, again, that no longer exist to be quite honest with you in most residency programs. It doesn’t mean that people have to be available and have to learn a lot. Again, when I look at the loads of information, when I was in medical school, graduating in 1976, medical knowledge was doubling every seven years. It’s now doubling in less than six months. So the reality, people are trying to learn far, far more than what we had to in those days. They have to learn more about ethics and many of the other social intricacies that involve medicine, they’re not prepared for the workplace, they don’t learn much about jurisprudence. They don’t learn much about the business of medicine and contracts and everything else. And it is very challenging when you’re trying to keep up, you’re trying to be abreast of the literature when disruptions are occurring daily, and you have all those other stressors.
Dave Kaufman – host: And no stress has been bigger on the medical community than the coronavirus pandemic. So let’s talk about COVID. So many of the mental health issues that Dr. Koyle has discussed so far predate COVID, but have been completely exacerbated by the pandemic.
Dr. Martin A. Koyle: You know, it’s funny that when we look at burnout, which you brought up a little bit earlier, burnout may be an end result to the disconnect that occurs between the organization or the system that we work in and that individual, and COVID really exacerbated something we call moral distress. And moral distress, it’s funny, when bad things tend to occur, disasters, we tend to go through phases as human beings and especially in healthcare where the impact after the disaster occurs leads to a temporary feeling of distress and worry. But then we become very heroic and remember all the applause for healthcare workers that occurred immediately after COVID, still coming to work, everybody cheering the medical professionals, and that’s the honeymoon period. But then, for instance, after a hurricane, yes, you see the aftermath quite quickly. There’s a short period of disillusionment before you have the feeling of reconstruction.
Dave Kaufman – host: That applause which was so heartening in the spring of 2020, seems like such a long time ago. More recently when the so-called Freedom Convoy was occupying Ontario cities and protesting in front of hospitals, healthcare employees were encouraged not to wear anything that would make them identifiable as a hospital worker.
Dr. Martin A. Koyle: And then getting back to the pre-disaster sort of mentality, COVID has been so long acting that that applause for the healthcare worker has diminished. As a matter of fact, there’s been antagonism as you know everywhere in Canada and the US in relation to anti-vaxxers in how they’ve looked at healthcare workers. So that period of disillusionment before reconstruction has increased dramatically, and many, many healthcare workers have thus been morally injured. So we’ve seen something that, yes, was described before, but now has had a much more major impact and that’s moral pain and moral injury.
Dave Kaufman – host: Dr. Koyle believes that one of the keys to surviving COVID and the myriad of other issues that medical practitioners get blindsided by on a daily basis is resilience.
Dr. Martin A. Koyle: I think for all of us, we have to realize that we all have inherent resilience and resilience simplistically is just our ability to recover or adjust easily to misfortune or change in the environment. And we all have different facets that allow us to be resilient and that includes our mental and physical health, our tenacity, our vision of the world, our ability to reason and maintain composure. And especially, I think in a sense of community and collaboration. I think what happened to me personally, and this is pre-COVID, is I felt that I was isolated, that there was nobody to talk to, and I didn’t feel comfortable speaking to other people. So if anything, I hibernated rather than sought help because I didn’t want to be judged as a failure, and I was so worried about how other people might look at me.
Dave Kaufman – host: As we wrapped up our conversation, I felt the need to see if Dr. Koyle had seen any improvements to the Canadian healthcare system since he arrived back in Canada. He points to digitization, a long overdue sign of progress, as well as the adoption of virtual visits with medical practitioners, which was practically unheard of prior to the pandemic.
Dr. Martin A. Koyle: Over the last two to three years, at least at Sick Kids and many of the hospitals in downtown Toronto and I can’t speak for the rest of Canada, the electronic health record has been implemented with some struggles initially, but ultimately I think it will be much better for patient care. And Alberta EPIC has now been provided by the province to I think, all the major health institutions, which allows communication throughout the province. And to me, it’s something we need to really advocate for nationally, not just provincially is the fact that we’re nomadic nowadays. It’s easy for us to move from province to province, from state to state, from country to country. And we need to realize that this is a technological age and we must devise systems which allow the healthcare to be portable.
Dave Kaufman – host: Finally, I asked Dr. Koyle if he has any faith left in the Canadian healthcare system. Unfortunately, like many Canadians who’ve had to navigate it themselves, Dr. Koyle gives the impression that for him to have faith in it, many improvements would have to be made.
Dr. Martin A. Koyle: I think the Canadian healthcare system has so many components, federally, provincially, at the macro level, at the meso level within the systems we work, so the hospital environment, and in the micro systems in which we work, which might be the team. For instance, a pediatric urologists that I work with at Sick Kids. The reality is funding is inadequate and it’s based on tax dollars. The number of hospital beds- I think what we’ve seen is that healthcare essentially is rationed to some degree and based on the fact that we’re at an equilibrium and a steady state, when something disruptive like COVID occurs, the whole system is sent out of whack and we realize we don’t have enough healthcare beds, we don’t have enough operating rooms.
Dr. Martin A. Koyle: And we’re really creating backlogs now of care that who knows when we’ll ever be able to catch up with. So I think it’s very important to be visionary, to learn from experience, to learn from our mistakes, to take what’s good, and to grow on the best parts of the system but we have to also realize that there’s many components that require improvement at all levels of healthcare and those have to be dealt with and focused upon.
Dave Kaufman – host: Dr. Koyle is clear. The tools exist to help, the medical practitioners need more support than they’re currently getting. If they don’t, the consequences for the future of healthcare and the Canadian healthcare system, more specifically, could be critical. Will doctors get the mental support they need to continue to do their jobs effectively and first do no harm? Will doctors learn that they can ask for help and that that superhuman attitude may be harming both them and their patients? And finally, will the COVID pandemic force Canada to bring its healthcare systems up to 21st century standards and give Dr. Koyle and his colleagues a fair chance at doing their jobs in a work environment that doesn’t feel, as he stated, like being in a time warp? Stay tuned as we navigate this new normal together.
Dave Kaufman – host: The New Normal is brought to you by Delve, the official thought leadership platform of McGill University’s Desautels Faculty of Management. I’m your host, Dave Kaufman. Producers of today’s episode, Dave Kaufman, Robyn Fadden, and David Rawalia. The technical producer of the New Normal is David Rawalia.