Podcast: Physician suicide
Transcript
Kirsten Patrick: Suicide is the one cause of death that is more common among physicians than nonphysicians. It could be considered an occupational hazard for physicians. It's a problem that needs to be discussed and needs to be addressed. I'm Dr. Kirsten Patrick, deputy editor for the Canadian Medical Association Journal. Today I'm speaking with the authors of a practice article on physician suicide, published in CMAJ. Dr. Joy Albuquerque is a psychiatrist in Toronto, and a medical director of the Ontario Medical Association’s physician health program. Dr. Sarah Tulk is a family physician in Milton, Ontario, and on faculty in the Department of Family Medicine at McMaster University. Welcome, Sarah and Joy.
Joy Albuquerque: Hi.
Sarah Tulk: Hello.
Kirsten Patrick: I'm going to begin by asking each of you to tell us a bit about yourself and about your involvement in physician health. Sarah, go ahead.
Sarah Tulk: Thanks, Kirsten. So for me, the involvement in physician health was actually personal. I had a depressive episode during my residency training. And through that, and through just talking about it a little bit, I came to realize that mental health conditions were actually very common amongst my peers and amongst other physicians, we just don't realize it because no one's talking about it. For me, realizing that I wasn't the only physician with these struggles, it really made my recovery so much easier. So as I started out, in my career, as a staff physician, I really wanted to help open people's eyes to the fact that they're really not alone in these struggles. And that this is a common issue that we really need to work on supporting each other through.
Kirsten Patrick: Joy?
Joy Albuquerque: I'm a psychiatrist. And I've been working for a lot of years in psychiatry, and for about 15 years in physician health. And so I've had conversations with doctors struggling with suicidal thoughts, and how challenging it is. When I think about, you know how I even got into this, it's a loss of somebody to suicide. And that's been that story that stays with me for many years now, as a resident, having a patient, not a doctor, die by suicide, and having the impact on me the impact on the team. So it's my pleasure to be here. And both Sarah and I wanted to thank CMAJ for both publishing and also for this, this podcast.
Kirsten Patrick: Joy, what do we know about the rate of suicide among physicians in Canada?
Joy Albuquerque: Well, that's a great question, Kirsten, what we don't know very much about the rates in Canada, and sadly, we there's not much published data. Most of it comes from the US in terms of statistics, and there's been some good meta analyses that have been done on physician in general. So most of us in this in this work would agree that Canadians have probably represented well by that data. And that data is really alarming. Both men and women in medicine, rates of suicide are higher than the general population, and women are three times higher, tend to be younger dying by suicide, and men are higher than the general population, almost double. So those are the rates that we have. Sarah you were gonna chat a little bit about the CMA survey. Maybe I'll turn it to you.
Sarah Tulk: Yeah, so Joy, that's the CMA national physicians health survey. They weren't able to look at suicide itself, but they were able to look at suicidal ideation. And the numbers are actually quite striking. Overall, physicians surveyed recorded a lifetime rate of suicidal ideation of 19%. With the 8% suffering from SI in the past year. One thing that I found particularly striking was looking at the data amongst medical learners. So residents reported a lifetime rate of suicidal ideation at 27% with 15% reporting in the past year, that's actually double the rate of staff positions, interesting residents, screening positive for depressions 48%, they didn't find any difference between specialty or practice setting. This is a problem amongst residents globally. So when we look at 15% of residents screening positive for SI in the past year, 50%, almost screened positive for depression. I think that's really tragic. You know, a 50% of our learners are screened positive for diabetes or some sort of malignancy. I think we should all be asking ourselves, like what's going on here? We'd be looking at our training environments to see what's happening to impart this risk, but because it's mental health, it seems that that doesn't happen. And I really think that needs to change. These students I mean, like the future of our profession, I think we need to do better to set them up for success. As medical students in particular, they're in such a vulnerable place. I teach at the undergrad level, and my students are worried that any of the whole thing they do or say will influence their CaRMS match. You know, they're afraid to see counsellors, they're afraid to go to their family doctors for mental health concerns, because they're worried it might jeopardize their match. And I think that's just so sad. Our profession imparts increased risk for dying by suicide, and then placed these obstacles between them and treatment. But I think it's also kind of amazing the potential we have with learners because they really present a unique opportunity to create cultural change, that we can promote good self care and normalize, receiving mental health care, right from the start, and we can make a huge dent in this issue of stigma.
Joy Albuquerque: Yeah, I couldn't agree more, Sarah, I think there are a lot of important pieces that need to happen, especially early on. I mean, we know that medical students come in for the right reasons, smart, young, empathetic, wanting to to do right by patients. And we see their empathy scores decrease as training goes by. Some of that you kind of expect will happen to some degree, because they must be able to have some stress tolerance, so that they can be there with patients who are suffering. But some of it is actually quite painful. And it's modelled perhaps by those of us who are into our careers. It's a culture in medicine, or some cultural aspects of medicine that, you know, which is about not talking about oneself, not talking about the problems, not talking about mistakes, that we're not supposed to, or that it's just not done. And therefore the idea that you keep everything inside you, and therefore, if you are struggling, well, it just is not normal to do that. And what a paradox, we find ourselves in that people who train to care for other people, are the very people who don't think they're worthy, or feel like they can't actually reach out for care of themselves.
Kirsten Patrick: One thing that I want to draw out at this stage, the article that you've written is about physician suicide. And what you're talking about here in this conversation with me, is how physicians struggle. And it always strikes me that a suicide, any suicide is a shock. And it wakes people up to an underlayer of discomfort and mental distress. But we never really think about that underlayer and treat that underlayer. We talk about only the shocking part, which is the suicide. And Sarah, you were talking about being open about your own struggles and Joy was talking about modelling. And then you said that there needs to be a culture change. What sort of culture change are we looking at?
Sarah Tulk: Yeah, you know, you're talking about the importance of driving change, and if I really want to answer that, because it's like, something tangible, but actually, I think that with this issue, talking about it really is driving change. One of the biggest barriers to physicians receiving mental health is the stigma surrounding it. And just by talking about it, we really can help break that down. I think the more physician to come out of the woodworks with their stories, and the more we hear about treatment successes, the more we give physicians permission to seek and receive mental health care, I think we really need to work towards this culture, where it's safe for physicians to access care, because we can put all the supports and services in the world in place. But if doctors are too afraid of repercussions, to access them, then it's not going to do any good. Michael Myers, who's done some really incredible work in this area, did a survey of family survivors of physician suicide, and he actually found that up to 15% of those who were lost to suicide never saw a treatment provider before their death. I think that's really just quite tragic. You know I think it's really sad that as a professional, we could let our colleagues reach a terminal stage of an illness without them ever seeing a treatment provider. Not even like not even one time. I really think we need to do better.
Joy Albuquerque: Yeah, Sarah, I mean, we're talking about physicians, but it's also some other health professionals who also have an increase in risk of dying by suicide as well. Because, in part, our, what I what I've talked about being the language of suffering, has been allowed to be sort of in the kingdom of being a patient and not in, you know, the idea of being a professional. No, we're not supposed to think of ourselves in that in that way. That's been a long, long standing, self sacrifice, giving oneself to the profession. I I'm a third generation physician and my father and grandfather didn't have a way to talk about, you know, the challenges that they might have felt they didn't put it into words. We started to in our generation, but I think it's fair and the next generations who are in some ways teaching us that this is important to have these conversations. It's important to be there for one another. And if we do, we'll actually be better at working together, better at being there for our patients. And then the other sort of more broad system is that suicide and suicidal ideation is, of course, seen in some of the more typical conditions, like severe major depression, or other mood disorders, or PTSD, or some of the post trauma kinds of circumstances that doctors find themselves in. But it is also in burnout, and in other stress-related moments, and incidents and events that a doctor can go through, that aren't actually associated with a diagnosis in the sort of more traditional DSM sense. And that is interesting. So you have you have people generally who are employed, generally who are married, then generally who have a fair degree of social economic support, and they are with suicidal ideation as a result of distress, or an adverse event, we have to elevate this so that people know that this can happen to any one of us. And I, you know, I often am talking to somebody who has reached a leadership level, and they will disclose how somebody died by suicide. And it was sort of on their watch, so to speak. And it has led to the them saying, you know, never again. And, you know, I'm thinking about the emergency doctor who sees a physician and feels like they're doing the physician a favour by assessing them and discharging them when they're sent in because of or go in, because they're, they're distressed. So sometimes I think for the wrong reasons people end up discharging, and not asking the questions about suicidal ideation. You know, we want to do right by our patients, but there have been physicians who have died by suicide, leaving the emergency room. And so I think it's a really painful example, that leads again to change. Because we need to be better at being able to be asked those questions. And because people usually say, when I'm talking to them that nobody's asked them if they're suicidal. It's almost like we're not supposed to ask, ask one of us if we might have those thoughts, because we're not supposed to have them. And so I think it's a really important piece, as Sarah was saying is that we need to have a safe place to tell these stories, because we need people to know that they're not alone, and that there is a way through.
Kirsten Patrick: Joy, I wanted to pick up on something. Earlier you were talking about sometimes, suicidal ideation and suicide are associated with mental disorders diagnosed mental conditions. But I think that the research on suicide shows that not every suicide is preceded by a diagnosis of a mental condition, and that there are other factors that contribute to suicide. Now, I remember, when I was a medical student, I was a depressed medical student. And as a junior doctor, I was depressed and suicidal, and also wasn't aware that depression was something that I would feel. It was the diagnosis that I had learned about at medical school that other people in psych hospitals had, but it wasn't what I had. And I remember the extreme tiredness of long hours of working and feeling ashamed of not doing right by my patients or feeling sad about losing a patient that sort of just tipped me over the edge to a feeling of I cannot carry on anymore. And I wonder about talking about those things in your article. When you talk about the high rate of suicide, when we get to why there's a high rate of suicide among doctors and in the community in general. Is it burnout, is it overwork, is it's a cultural thing, what are the biggest components?
Joy Albuquerque: Thank you for sharing, Kirsten. It's very much we see the same CMA survey that that Sarah mentioned earlier, also shows that the higher rates of depression, at least by screening are there within our program, whether those are actually clinical depression or whether they are, you know, sort of more of an adjustment or sort of minor depression. We don't really have a DSM for situational issues that are occurring over time. But what we're finding is and especially in the younger residents and medical students who are more likely to get help actually, which is heartening, really, that they're being treated for that whether or not it's depression or not, they're being treated psychotherapy, sometimes with medications. And they're saying, wow, I cannot believe the difference, I cannot believe how I felt, I thought was the norm, kind of what you were talking about. You know, it's difficult when you're the frog in that water getting hotter and hotter to know whether or not that is, you know, actually getting hotter, or if that's actually a problem that I have. So I think it's really when we're there, and somebody sees us shifting from our baseline, because usually, somebody around has noticed something, they just haven't necessarily thought it was as serious as what's going on inside the individual, because we hide a lot. And we feel kind of better at work. So people might not notice. But if somebody notices a shift, that's where I really love that message to get out, you know, ask somebody, are they okay? You know, and then be be there to get them to that next right step, which could be the family doctor, it could be all the way as an emergency to the emergency room.
Sarah Tulk: Joy I thought you mentioned a really good point there about how hard it can be to be both a health care provider and a health care consumer. We're so used to being on the doctor side of that doctor-patient relationship, that to step into that other role, even if it was for something organic is uncomfortable. We're doctors, we don't like playing patients, we don't make good patients. And then when you add that intense stigmatization that's affected mental health care, it can really become an impenetrable barrier. I know, for me, but you know, I have a fantastic psychiatrist, I can't speak highly enough of but I don't like using the front door to his clinic. It seems awkward. I'm used to using the back door. I don't like sitting in the other chair, you know, I'm used to being at the computer. It's very strange, very unnerving. And I think when you take someone who's already in a particularly vulnerable state, and now we're asking them to sit, you know, in the opposite chair to take that opposite role, for some people, the answer's no, I can't, I can't do that. And I think that that's also a good place where our colleagues can come in in supporting one another.
Kirsten Patrick: What do we know about the means of suicide among physicians?
Sarah Tulk: Yeah, so if you look at the literature, depending on this study, the most common method is firearms, or poisoning, with the most common medications being barbiturates in most studies, but also benzodiazepines and antipsychotics. There was another study that showed that blunt force trauma and [inaudible] which included hanging, were also more common in physicians than in nonphysicians, but it was that self-poisoning, that's most common.
Joy Albuquerque: In my experience, the doctors tend to use medications, but they use medications in a way that they know will have that impact. People need to know both facts. They need to understand the seriousness, because we know how to do it, you know, we have the means, we have the prescription pads, and we know how to do it and do it effectively. We could be pretty scary I think when we we turn our minds to that. We don't know what the stats are for doctors with substance use disorders, because some become such high risk of dying by suicide, but also at such high risk of overdosing and dying like in the opioid crisis that people know about today. We've known about the opioid crisis in medicine for a long, long time. There are aren't too many doctors who die because they've adjusted their dose wrongly and are found with the IV in their arm. So the idea of using medications but also using multiple modes as well. So it's not infrequent that a doctor will try actually using a few modes to ensure that they are going to die. They don't want to be found and they certainly don't want if they are to have any injuries or impact on somebody else. If there's any morbidity.
Kirsten Patrick: In your article, you also mentioned that the rate of suicide is higher among physicians who have either a past or current regulatory complaint against them. Can you tell us what you think that means?
Sarah Tulk: Yeah, so anecdotally, I think we all know how stressful receiving a complaint and working through that process can be. But reviewer actually pointed out this excellent study from the UK that quantify that risk is really quite striking. So physicians without complaints reported SI to rate of two and a half percent. But those with the current or recent complaint actually had rates of suicidal ideation almost four times higher than the baseline. And if you looked at anyone who had ever had a complaint, that increase was over a five-fold.
Joy Albuquerque: And I think there's CMPA had done a study some time ago, a few years ago, looking at stressors and the impact on on physicians. And there was no question that the highest stressor was a patient complaint, or a CPSL regulatory process. And what we know is that in the last over the last decade, with lots of pressures, there has been increased demand for transparency, about a lot of things. And that has led to changes in the questions that are asked on our applications for licensure and our re-applications, asking for more details about health. So not only do complaints and the complaint process, which, as Sarah mentioned, is incredibly stressful for us. I mean, the chance that you may have sanctions or your fear that you in some way may lose your livelihood or your job, or that people will treat you in a different way. There's that part. And then on top of that, we're being asked more information. And that has been over and over again, shown to, if anything, to make people less likely to get help. And there's this wonderful study that was done looking at a Facebook group where female physicians and moms who have in strong populated this Facebook site and are really using it. And they did a study on that looking at that group. And they said just an overwhelming number of them said that they would not seek help when they were feeling not okay, because it wasn't safe to do so, that it would lead to some negative consequences. And to me, that's all shocking, but very alarming, especially when we start to see how closely burnout and stress is tied to suicidal ideation.
Kirsten Patrick: Physicians who have suicidal ideation face unique barriers to care. What are those barriers?
Joy Albuquerque: Yeah, and, you know, it's interesting, I think they the barriers, and I'd love to see them turn into hurdles, and have them be hurdles that get smaller, so that we're getting past them. But you're you're right, there are, there are barriers that come from people being afraid, afraid that there is no treatment, afraid that there isn't help, afraid that the there would be a negative impact to them afraid that they will lose a job. This is now a time where in some areas in medicine, it's more difficult to actually compete to get jobs, particularly if they're, you know, needing an operating room or operating time. And if somebody has a health condition that might be seen to be perhaps increasing a risk to them in some way, are they going to be as competitive. And so there are a lot of fears when you have health concerns. But then we're also concerned about how people might judge us, you know, how we might be looked at as weak, a weak link or not part of the profession in terms of feeling weak. And judged as that there are a lot of concerns about that. People fear about their confidentiality, that health information is just going to get broadly, you know, almost broadcasted around and everybody will know. People worry about it being on the website, especially in the CPSL. There's all these fears that are happening, and some of them are realistic. I mean, there are major challenges with how we're regulated, and the fact that we are safety sensitive occupations, and that we do work and have our jobs because the public trust us. So there's a lot that we understand and that we do need to be accountable. But at the same time, we don't want doctors to feel like they can't get their health needs met. And there is still a stigma and discrimination, you know about mental illness that perhaps we as doctors have for ourselves. I know that some very prominent doctors have talked about self-stigmatizing themselves as they have health health concerns. And but then maybe we carry some implicit biases about this that impact how we relate to somebody who might have a health condition or how we interact with somebody. And I think those are those important cultural pieces, again, that we need to address. You know, we all have biases, we all have assumptions and we we need to still sort of have them, but also be willing to be there for somebody.
Sarah Tulk: Yeah, if we go back to the CMA National physician health survey, there are top reported barriers to seeking help. Number one was believing that situation was not severe enough. And number two was feeling ashamed to seek help. And I think that that's something you really hit on the nail there, Joy. I mean, if we were to think like, I mean, if you or I, or anyone were feeling suicidal, and needing help for that, you know, let's just go through the barriers that would be in place. First, you need to realize that, which can be hard as some mental illnesses rob you of your insight and can create this tunnel vision, where suicide seems like the only solution. But if you were able to get past that, and now, presumably, we're talking about voluntary treatment, you'd have to have at least some degree to want to be treated, which might be hard when throughout your career, your profession has told you that you shouldn't need to depend on others for help. You should be strong, you know, you should be the ultimate stoic. Doctors help others, they don't take help from others. You know, then you'd have to find a provider. What if you're in a small town, like I think about our rural colleagues, you know, you worry about judgment, you might worry about confidentiality. Where do you go when you're one of the only providers? It's, it's hard, it's hard to access health care as efficient, it's hard to get over the shame. And it's hard to get past the stigma, both from colleagues and also, as you mentioned, Joy from from yourself.
Kirsten Patrick: It's really important to have conversations like this conversation we're having here today. But it's just as important to drive change. So what do you think needs to be done to address physician suicide in the next few years?
Joy Albuquerque: This is larger than every one of us. And yet, every one of us will likely either be touched in some way or experienced their own personal distress, or need to act. But on the large issue, I think, you know, CMA has got a great policy on on physician health. Each province across the our nation has physician health programs. You know, we need to make sure that all doctors have family doctors, and I think now all of the medical schools across our nation have wellness programs and are looking at not only for the undergrad and postgrad, but thinking about fellows, as well as for the staff, who are, you know, working within the system. And then that leaves the community docs and the community docs in hospitals and then the rural and the remote. So how do we ensure that these messages get across that this profession actually cares about and matters to them? That that every single person has equitable access and equitable workplaces? You know, I think those are the larger discussions are starting to happen now, with the Royal College who is looking at the CanMEDS, and how to have competency based medicine. What does it look like to be a professional currently now not just how it was in my dad's day, but you know, what does it look like now and to the future? So I think there's a larger issue that is going to drive change. But maybe Sarah, I'll turn it to you to talk a little bit more from your perspective.
Sarah Tulk: Yeah, so she asked about what needs to change. So I think about what do we need in order for people to access care. And so number one, we need the services. And number two, we need people to feel safe using them. So I think you make a really good point about every physician needs a family doctor. I think as a family doctor myself, I might add that it's helpful if family doctors and other physicians have some education on how to treat physician patients, because there are some nuances that are a bit different. It can be a bit of a different dynamic than patient who is not also a colleague. I think, you know, looking at services through physician health programs, I think, you know, medical schools are adding in honours programs and counselling, which I think is fantastic. I think one part of accessing services is also looking at a time factor, which is particularly an issue for medical learners, they have almost no control over their schedule, to make it to see a counsellor who's only working nine to five, I mean, that can be that can be almost impossible. And unpredictability of call schedules can make it hard to make appointments. So we also need to look at that access perspective. And then people need to feel safe and I think we've talked a lot about safety and stigma. You know, you have to know that you can accept care and you can feel comfortable that this will stay confidential. If you know you do share, you have to feel confident that you're not going to see your referrals suddenly drop off or you're having like, a harder case is not coming to you, you're not going to have troubles with privileging applications, you're not going to have trouble with faculty appointments or teaching positions. You need to know that nothing is going to change, except, or have support from the workplace if that's something that you want and was helpful. But you have to feel protected from negative consequences as a result of seeking care.
Kirsten Patrick: So I like that you outline the real practical things, because I'm going to play devil's advocate here. And I hear a lot of residents saying, you know, my hospitals got resilience training, and it's mandatory, and it's more stressful to go to resilience training, and then they feel like they've ticked the physician wellness box, or my hospital has a physician wellness program, but I don't feel that there's anything different. We're just taught to be mindful.
Sarah Tulk: That's a really good point, Kirsten. I I've heard that said, as well. I think resilience programs, while the intention maybe could kind of miss the mark, if we look at, you know, the definition of resilience, you know, you need to have a stressor, a fall from baseline function, and then a return to baseline function. Residents are resilient. At some point, we have to look at the environment. What are we asking them to come back from? And how can they come back when a stressor is never removed?
Kirsten Patrick: Yeah, that's really powerful. I think that an element of resilience has happened already, before we get to that point, right. And so saying, oh, be more resilient, when you've already exhausted your resources of resilience is kind of counterproductive.
Joy Albuquerque: I feel pretty strongly that this isn't about resilience. And in fact that CMA health survey talks about our made measures of you know, well being and how how we're flourishing and how are we feel our health is actually. Our well being is pretty good. So here we have resilience, while being flourishing being sort of high levels in medicine. And yet burnout is high and suicidal ideation and depression scores. So I think there's something really interesting here, we've got people who are actually really good at stress, really good at managing stress, who are who tend to be more more resilient, in general. This is something different, you know, the world we work in is different, how we practice medicine is different the demands on us, the multitasking, the EMRs, all kinds of things that are happening that are distancing us from our patients and, and changing how we work, are some of the stretches that people are talking about, that are really eroding us. You know that whole idea of getting burned out, because it's just this uphill battle of of trying to work in the way we want to work. And yet, we can't, or it takes us much longer. So, you know, I think there's the message that we somehow have to build resilience. Sure, I think on some levels as a psychiatrist, I believe, we need to learn coping mechanisms. But in general, I think we're pretty darn good. So there's more to this than that. And I hear that too, that medical students and residents are sort of saying if somebody mentions, you know, burnout or resilience one more time, I'm going to scream. You know, those kinds of things are happening at the same time, that leadership is actually listening and starting to make changes to the from that top down, which also needs to happen. So we have hospitals like in Ottawa, where, right from the CEO down, there's an adopted concept that wellness and health of staff matters at a corporate level. And what happens when that starts to take place in a in a university where a dean says, our strategy builds in a physician wellness, trainee wellness, resident wellness, into the fabric of the strategy. And I think those are the other things that are happening and need to happen. It can't just be, you know, a mindfulness class and God forbid if it's at 8.30 in the morning, that doesn't make sense.
Kirsten Patrick: So one last question today for anyone listening who's struggling, having suicidal thoughts or for people who know somebody who really needs some help, what advice would you have?
Sarah Tulk: Kirsten, so that's, that's such a hard question for me to answer. It's difficult because I've been there. I remember quite vividly, how incredibly isolating and painful it is to harbour suicidal thoughts. I think that what I would say is that even though it really really feels like it, you're not alone. You're not the only one who's had these struggles, other physicians have been where you are, they've come through the other side. And, you know, not to sound trite, but you can do it too. I'd encourage you to remember that, you know, this doesn't make you weak, it doesn't make you less than, it doesn't mean you're not cut out for medicine. It just means that you're human. And maybe you're a little bit sick. And maybe you need a little bit of help right now. I'd want you to remember that suicidal ideation is a symptom. It isn't you, it isn't even necessarily a thought you'd you want. But it's a very scary symptom. If not addressed, it could be fatal. So I really, really encourage you to please please don't ignore it, tell someone tell it tell, you know, really, anyone you think might be able to help you get the help you need. I bet you'd be surprised by how many people want to help. You know, you could consider calling your PHP, you can talk to your family doctor, if you have access to one, you could talk to a colleague, if there is someone you trust, just tell someone. And then if you're that someone, I would say to take suicidal ideation in a physician very, very seriously. We've talked before about how physicians have the means and the knowledge for highly lethal suicide attempts. So prevention of that attempt is really, really key. So take it seriously, and help them get help. They're struggling with enough right now. And if you know you can be the link between them and care, you would be doing them immeasurable good service.
Kirsten Patrick: Thank you, Sarah.
Joy Albuquerque: So I really, I think I just need to emphasize what Sarah said, you know, you're not alone, and that you really deserve the chance for care. And I know that as colleagues that we want to be there and we want to be able to help. For those of you who are worried about a friend or a family member or colleague, please don't stay alone with this. As Sarah said, you know that we're there are lots of routes to be able to help. And at the same time, that we're always resolved towards perhaps that zero rate of suicide, which I hope is possible. And for us to be there to work together, but to be there together, to not to judge and to support somebody back to a healthier place.
Kirsten Patrick: Thank you both for taking the time to speak to me today. I'm so grateful that we've had this good conversation about this difficult topic.
Joy Albuquerque: Thank you, Kirsten.
Sarah Tulk: Thank you so much, Kirsten. We really appreciate the chance to expand on our five things article, which is a great snapshot. But there's so much more to be said. So, I know we really really appreciate the chance to come on this podcast and get to explore this topic further.
Kirsten Patrick: I've been speaking with Dr. Joy Albuquerque, a psychiatrist in Toronto and medical director of the Ontario Medical Association’s physician health program. And Dr. Sarah Tulk, a family physician in Milton, Ontario. To read the practice article they co-authored visit cmaj.ca Also, don't forget to subscribe to CMAJ podcasts on Soundcloud or a podcast app and let us know how we're doing by leaving a rating. I'm Dr. Kirsten Patrick, deputy editor for CMAJ. Thank you for listening.