An open letter to the Prime Minister of Canada and the Premier of Alberta

An Open Letter to The Prime Minister of Canada and The Premier of Alberta

Dear Prime Minister Justin Trudeau and Premier Rachel Notley:

The quality of health care systems and patient safety depend heavily on high-functioning health care professionals.

Recent studies, however, have revealed, what was already informally known – an alarmingly high prevalence of burnout, emotional exhaustion, interpersonal disengagement, and a low sense of personal accomplishment amongst the health care professions.

Many recent publications are warning about the continual rising levels of burnout rates amongst health care professions — having reached an “epidemic” level already.

With compelling evidence now available, there is a real sense of urgency for our leaders to realize that burnout is having devastating consequences for those affected, their colleagues, patients, and the healthcare system as a whole.

Burnout is defined as “prolonged response to chronic emotional and interpersonal stressors on the job”. It comprises of symptoms such as:

• Emotional exhaustion • Depersonalization • Diminished satisfaction with one’s work

Burnout has been documented since 1981. But despite several studies indicating to a growing crisis since then, little or no effort has been spent in dealing with this issue, now an epidemic.

Burnout has been linked to:

• Diminished professionalism • Increased medical errors • Poorer patient outcomes • Worse health care economics • Depression in those affected • Alcohol misuse • Substance misuse • Suicidal ideation – and tragically increasing number of actual suicides • Poor family dynamics / relationship breakdowns

Despite these known facts, little or nothing has been done to address the core issue at hand – what is leading these bright minds to be affected in such a manner or to even understand the factors, often systemic or institutional, that are contributing to this epidemic.

We are now seeing a sudden increase of studies coming out reporting the scale – still underreported in many people’s opinion – of burnout amongst many specialities in health care. While the system continues to put up intense resistance, many are buoyed by the availability of social media and other web-based modalities in reaching out to audience globally.

The importance of professional culture and the working environment is now being recognized as a critical factor leading to burnout amongst professional. For example, burnout is viewed by some as an “inevitable consequence of the “hidden curriculum” in medical education, where learners witness and adopt their teachers’ maladaptive behaviours, which are often reinforced throughout their careers.”

Poor learning environments in medical institutes, such as disorganized rotations and inadequate supervision, are also associated with learner burnout.

Chaotic clinic settings with bottlenecks to patient flow, lost charts, collection of meaningless administrative data in the garb of “patient and health care outcomes”, are just some of the most basic examples of what can lead to physician burnout, as well as medical errors.

Doctors are often seen struggling to maintain performance standards in a chaotic and unpredictable work environment by “using adaptability, flexibility, interpersonal skills, and humor to diffuse stress.”

Definition of Good Mental Health.

The World Health Organization defines good mental health as “A state of wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her or his community.”

Thriving at work – The Stevenson / Farmer review of mental health and employers.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/654514/thriving-at-work-stevenson-farmer-review.pdf

On Jan 9, 2017, the Prime Minister of United Kingdom, Theresa May, called for an independent review into “how employers can better support the mental health of all people currently in employment including those with mental health problems or poor well-being to remain in and thrive through work.”

The release of the review this week couldn’t have been timelier.

This report highlights that “UK is facing a mental health challenge at work that is much larger than we had thought.”

It further states that “not only is there a big human cost of poor mental health at work, there are also knock on impacts for society, the economy and Government. Employers are losing billions of pounds because employers are less productive, less effective, or off sick.”

Some salient facts from this report are:

1. 300,000 people with a long term mental health problem lose their jobs each year - at a much higher rate than those with physical health conditions and about the size of a good-sized city.

2. Mental health costs per employer in health sector around £2,174 (highest amongst all public-sector departments)

3. 2016 NHS Staff Survey found that 37% of NHS employees had experienced work-related stress.

4. Large annual cost to employers of between £33 billion and £42 billion – over half attributed to individuals being less productive due to poor mental health at work – a phenomenon now described as “Presenteeism”.

5. Cost of poor mental health to UK Government is between £24 billion and £27 billion.

6. The cost of poor mental health to the economy as a whole is more than both of those together from lost output, at between £74 billion and £99 billion per year.

7. The human cost is huge, with poor mental health having an impact on the lives of many individuals and those around them.

8. Ultimate human cost of loss of life through suicide. (An estimated 400 physicians die of suicide in the USA every year – grossly under-reported as most deemed “accidental or natural” deaths)

The report has further laid out Core Standards as well as Enhanced Standards to ensure wellbeing at work. Furthermore, it has also described in detail the role government can play in dealing with this epidemic.

Pertinent recommendations from this report are:

1. The need for a self-sustaining and measurable change process that is visible.

2. The Importance of Transparency & Leadership: Legislation and guidance, to encourage employers to report on workplace mental health on their website or other channels.

Increasing employer transparency presents the biggest opportunity to encourage a greater breadth and depth of employer action on mental health.

Strong leadership is vital to ensuring this change is felt throughout organizations.

“In my experience, there is a strong correlation between the authenticity of an organization’s support and commitment and the willingness of staff to speak up. This is governed by how supported individuals feel and how visible, active and credible their most senior leaders are on this front.”

Jeremy Heywood, Cabinet Secretary, UK

3. Senior management in the public-sector should have their employees’ mental health and wellbeing as one of the criteria by which their performance review is assessed and linked to the regular delivery of measurable results so as to ensure that there is real meaning behind the assessment.

4. External Support for Employers: External groups can provide vital guidance and support to enable employers to implement the mental health core standards, and take steps to support increased employer transparency and accountability on workplace mental health – by helping develop standards, and by developing online comparison tools, for e.g.

5. Role of Regulators: Professional bodies with responsibility for training or accrediting professional qualifications should include workplace mental health in their training programs and assessments.

6. Support for private SMEs: Government and other organizations should focus information, support and funding to support small and medium sized enterprises to help with implementation of the mental health core standards, and ensure the impact of this is evaluated.

7. Support Research and Innovation in workplace mental health: Government streamlines research and activity relating to workplace mental health to drive evidencebuilding and innovation, putting it at the heart of their future strategy.

Canada has a Mental Health Framework called “The Standard”?

It was news to me in reading the report mentioning “Canada has a workplace mental health framework – The Standard”

Apparently “Canada has a structured framework for workplace mental health. The framework, called ‘the Standard’ provides a comprehensive framework to help organizations of all types improve their workplace mental health offer to provide the best return on investment.”

It further states that apparently “The Mental Health Commission of Canada has developed a variety of resources to help organizations implement the Standard.”

My Immediate thoughts:

• How is it that none of the health professions’ system leaders and front-line workforce know anything about this framework and the resources developed?

• Should the system leaders not be made accountable for this?

• This obviates that the most critical of all the recommendations: The importance of leadership role and transparency.

Results of a Canadian study done in 2014

(Dewa CS, Jacobs P, Thanh NX, Loong D. An estimate of the cost of burnout on early retirement and reduction in clinical hours of practicing physicians in Canada. BMC Health Serv Res 2014;358:254. doi:10.1186/1472-6963-14-254 pmid:24927847)

• •

Total estimated costs of burnout for all physicians practicing in Canada per year: About $213.1 Million (grossly under-estimated)

Of this, $185.2 Million is attributed to early retirement and $27.9 Million due to reduced clinical hours

But what about the indirect costs & effects of health care professions burnout?

Conclusion

Prime Minister Trudeau and Premier Notley, health profession is in crisis mode. We need your urgent attention and intervention to address the most pressing issue at hand – To meaningfully address the burnout crisis amongst the health care professions.

Any attempts to produce better patient care and health care quality outcomes are utterly and totally futile unless we deal with the core issues leading to a burnt-out workforce, unable to deliver on right care and patient safety.

Appropriateness in health is inappropriate without including health professions wellbeing.

In times when efforts to employ concept of ‘appropriateness’ in health for system sustainability is a priority for health care leaders and government alike — workable solutions and quality improvement initiatives must include health care professions wellness and wellbeing as an essential quality and patient safety indicator.

Accountability of Health care organizations and leaders is of paramount importance.

Health care organizations & leaders must embrace their responsibility and be made accountable in building an efficient, supportive, open workplace environment — to foster a culture of wellness & openness, while also supporting health professions’ efforts to improve their own health & wellbeing.

We must realize and accept the role of behavioural insights & design-thinking in codeveloping workable solutions.

To guide the development of appropriate policies and decision-making processes in order to foster health care professions wellness and wellbeing.

Personalization of Initiatives.

Personalization of health professions lifelong learning / professional development initiatives — including leadership development — can help foster ownership within the health care professions, thereby increasing value and joy in personal lives, as well as practice. Urgent help is needed in supporting such initiatives.

Although, care must be taken to ensure that any personalized initiatives launched are not just "token" programs. Fundamental concept of all such initiatives must be to move the paradigm in health care system from "what's the matter with you" — To "what matters to you".

I thank you both sincerely for taking the time to read my letter and look forward to your replies.

Yours truly,

Khurram Jahangir (drkj74@me.com) An Ordinary Physician - Practicing in Edmonton