Caring is the core of every health care system. A successful health care system promotes a wellness of mind, body and spirit, and prevents and treats dis-ease in each member of a society, as the ultimate fruition of every decision made in administering this system.
Such systems, however, do not exist in a vacuum. The pandemic and the climate crisis remind us that we are, as well, a global society — interdependent with each other and with the natural environment in which we live.
In the recently published Improving Accountability in Health Care for Canadians, the CMA identifies key indicators of performance as the first step in ensuring accountability and success. “To provide Canadians with an accurate picture of how the health system is performing and what needs to be improved, metrics should address the patient journey. “. The publication goes on to name these metrics – Throughput, Societal Impact, Personal Impact, Ease of Navigation, Ease of Access, etc.
These performance indicators effectively represent the prevailing paradigm in our Canadian Health Care systems – patient centered care. According to a 2017 article in the New England Journal of Medicine, “In patient-centered care, an individual’s specific health needs and desired health outcomes are the driving force behind all health care decisions and quality measurements.” Patient centered care is the foundation of our decisions, policies and practices. It is the basis of what we learn in medical school, and the priority and focus of all that we do as clinicians. Any measure of ‘success’ must, therefore, be in accordance with this paradigm.
According to the CMA Physician health survey of 2021, 53% of all Canadian Physicians met a criteria for burnout. For residents this number was as high as 58%. In the same survey 1 in 4 of all Canadian Physicians reported moderate to high anxiety, and 48% screened positive for depression. Burnout has significant personal and professional repercussions. Personally, burnout is associated with increased depression, divorce, addiction, suicide and disability. Professionally, burnout is connected with increased physician turnover, poor patient satisfaction, increased medical errors, and reduced quality of care.
In a patient centered care model, where does the health of physicians fit in? Adhering to such a patient centered paradigm, physician wellness is relegated to the periphery of priority, and sleep deprivation, over-busyness, and working sick or injured become the accepted norm in a medical culture of self-sacrifice. The challenges of staff shortages, clinic/ER closures, and poor patient access to care, that we are witnessing across the country, are the inevitable outcomes of a system that has not prioritized provider care and wellness as a necessary foundation of all that we do.
The climate crisis is now moving beyond the purveyance of scientists and environmental activists, taking its proper place at key decision making tables, in the headlines of major media, and in the minds of individuals, companies and governments across the globe. Warming temperatures, rising ocean levels and extreme weather events are affecting food production, fresh water access, vector-borne disease prevalence, refugee migrations and political stability. These, in turn, have profound repercussions on our societal health — from the direct dangers of extreme weather events on respiratory and cardiac events to malnutrition, violence, mental health and infectious disease. The Canadian health care system is responsible for 5% of all greenhouse gas emissions in Canada, which is equivalent to other major industries such as aviation. One single metered dose inhaler has the same carbon footprint as a 290km drive in a standard gas-powered vehicle.  And according to the UN Food and Agriculture Organization, global livestock production for meat consumption accounts for 14% of all greenhouse gases. How we practice medicine – from the waste we produce to our medication and lifestyle prescribing practices – have profound impacts on the climate crisis. Switching to dry powder inhalers for asthma, reducing waste in our clinics and hospitals, and encouraging a plant based diet for our patients are simple actions that can have profound repercussions on reducing our carbon footprint, and mitigating the inevitable, significant, health effects of global warming.
In order to address the challenges of this modern era, we need a paradigm shift in health care, from one that is patient centered to one that is human and Earth centered. We must recognize that broadening our focus to the health of providers and recipients of health care allows for greater sustainability. When our health care providers are thriving, we are better able to care for our patients, and for each other. Medical errors and disability would decline, and we would ensure a more stable work force by encouraging support, a culture of wellness, and healthy places of work.
As our new paradigm includes the health of the natural environment in all of our decisions, policies and practices, we would begin mitigate the impacts of health care on pollution and the climate crisis, and would take our rightful place, as responsible citizens on a global stage.
Such a change in paradigm is not easy. There is a seduction to sameness, and a tyranny of the status quo that prevents us, as individuals and as organizations, from growing and adapting to evolving conditions. And yet, we are in the midst of the consequences of a limited and outdated paradigm in health care. The courage to adapt is before us, and will require a transformation in our strategic planning, policy development, resource allocation, clinical guidelines and educational systems.
Perhaps it begins with how we measure performance? If our key performance indicators of our health care system continue to be only ‘metrics (that)… address the patient journey’, then they will continue to be an important, but inadequate, representation of the health of our system. Over 14 years ago in the Lancet, JE Wallace began this conversation with the assertion that “ health systems should routinely measure physician wellness, and discuss the challenges associated with implementation.” Since then, numerous studies and reviews have documented the health care impact of provider burnout, suggesting concrete measures of assessment in order to evaluate this. In 2019, a UK based group called Health Care Without Harm documented Britain’s National Public Health service which reduced carbon dioxide emissions by 18.5% between 2007 and 2017, despite increasing clinical activity. We are not alone, and there is both precedence and collaborative opportunities that await.
The courage, perspective and willingness to change is before us. We can continue to rearrange the deck chairs on the Titanic, or we can recognize that the crises we are facing perhaps have more to do with the lens we are looking through than the specific policies we are implementing. As we begin to measure health provider wellness, and our carbon footprint, as first steps in our paradigm shift in health care, perhaps we can move towards a system that is truly more sustainable, efficient and caring.
1. Improving Accountability in Health Care for Canadians. www.cma.ca/sites/default/files/2023-07/Indicators-Report-EN.pdf
2. What Is Patient-Centered Care? NEJM Catalyst, January 1, 2017. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559
3. CMA 2021 National Physician Health Survey Prepared for the Canadian Medical Association August 24, 2022. www.cma.ca/sites/default/files/2022-08/NPHS_final_report_EN.pdf
4. Physician burnout: contributors, consequences and solutions. J Intern Med, 2018 Jun;283(6):516-529. https://pubmed.ncbi.nlm.nih.gov/29505159/
5. The Health Effects Of Global Warming: Developing Countries Are The Most Vulnerable. Vol. XLIV, No. 2, “Green Our World!”, 2007. https://www.un.org/en/chronicle/article/health-effects-global-warming-developing-countries-are-most-vulnerable
6. Acting on climate change for a healthier future, Critical role for primary care in Canada. Edward Xie, Courtney Howard, Sandy Buchman and Fiona A. Miller, Canadian Family Physician, October 2021, 67 (10) 725-730; DOI: https://doi.org/10.46747/cfp.6710725
7. CMAJ Pressurized metered-dose inhalers and their impact on climate change
Lee Fidler, Samantha Green and Kimberly Wintemute
CMAJ March 28, 2022 194 (12) E460; DOI: https://doi.org/10.1503/cmaj.211747
8. Major cuts of greenhouse gas emissions from livestock within reach. Food and Acricultural Organization of the United Nation. 26 September 2013, Rome https://www.fao.org/news/story/en/item/197623/icode/
9. . Physician wellness: a missing quality indicator. J.E. Wallace et al..Lancet, (2009)
10. . Selecting physician well-being measures to assess health system performance and screen for distress: Conceptual and methodological considerations. Keri J S Brady 1, Lewis E Kazis 2, R Christopher Sheldrick 2, Pengsheng Ni2, Mickey T Trockel. Curr Probl Pediatr Adolesc Health Care 2019 Dec;49(12):100662.
11. Longitudinal study evaluating the association between physician burnout and changes in professional work effort. T.D. Shanafelt et al..Mayo Clinic Proceedings; (2016)
12 Health care’s climate footprint. How the health sector contributes to the global climate crisis and opportunities for action. Karliner J, Slotterback S, Boyd R, Ashby B, Steele K. Health Care Without Harm; 2019. Available from: https://noharm-global.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf