Creating space to improve personal and professional care with Dr. Nadine Laraya

In studio today, we have Nadine Laraya, community family physician in West Toronto affiliated with St. Joseph's Health Centre, a community family medicine liaison to St. Joseph's Centre and a lecturer at the university of Toronto. Today's episode focuses on the importance of pacing oneself and creating space to improve personal and professional care. 

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Dr. Rezmovitz 0:00

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Nadine Laraya, community family physician in West Toronto affiliated with St. Joseph's Health Centre, a community family medicine liaison to St. Joseph's Centre and a lecturer at the university of Toronto. Today's episode focuses on the importance of pacing oneself and creating space to improve personal and professional care. Hi Nadine, and welcome to Small Changes, Big Impact.

Dr. Laraya 0:42

Hi Jeremy. Thanks so much for having me on the show today.

Dr. Rezmovitz 0:45

Yeah, I think we're going to have a lot of fun today. So tell us a little bit about yourself.

Dr. Laraya 0:50

Well, I'm a family physician as you know. I practice on the West side of Toronto. I work with a wonderful group of people. I love being a family doctor and I also have a family of my own - two daughters: 8 and 10, and I just enjoy living in the city.

Dr. Rezmovitz 1:11

Awesome. So I'm going to try something new on the show that we haven't done before. And tell me something good that's happened to you already today.

Dr. Laraya 1:20

I took the subway for the first time in a very long time. I normally drive to work because I work in a bit of a surburban area, but I love coming downtown because it's a chance to get on the subway. And I made a very conscious choice to wear a bright red jacket, which in Toronto you don't see very often. So I got on the subway into a sea of black and brown and beige, and I just felt like I walked on there and I was the only person in red. And I looked around and I got a couple of nods and a couple of smiles, and that was kind of a nice thing. It was so small, but it was like, you know, I was wondering if I should wear this jacket. And I did.

Dr. Rezmovitz 2:06

I saw you come in. I also had the same thought. Your red stood out here in the studio actually, between what Brian and I are wearing today. So based on, you know, trying to springboard off of something good that's happened to you already today , today's podcast as we've kind of discussed, is really about also the small change, right? Like you just mentioned that the red jacket - you've got some nods, it made some changes in some people - like you saw that it was a small little change. So we want to hear about other small changes that you've made and why you made them.

Dr. Laraya 2:43

So I've been part of the department since I finished residency back in 2008. I was lucky enough to be offered a position in the teaching unit at St. Joseph's Hospital, which was an amazing experience. And I've since moved on to the community, which has also been a really good experience. My career trajectory has shifted over the last 10 years or so I've been in practice . As I've changed as a person , I've come to really, I would say, be in a good place when it comes to wellness. And that is a topic that comes up a lot in our circles. We talk a lot about physician burnout. We talk a lot about what it takes to achieve physician wellness. And the current state of my story , I would say is very positive. I'd like to share that I'm a physician who might've actually achieved a balance where I feel like I'm practicing what I should be. I'm achieving other things the way I want to be and I get the leisure time the way I want. It's happened by design over a number of years , and through a number of small changes and it has come at a little bit of a cost to myself, but I'm really happy where things are right now and it's put me in a position to maybe make some transformations in the profession as a whole.

Dr. Rezmovitz 4:26

So would you mind sharing how things have changed from when you started and where you are now?

Dr. Laraya 4:33

So this brings me back to a story that - I can't even remember if it was seven or eight years ago, but one of the key parts of my work week or my career at the time was working on call in obstetrics. So delivering babies as a family doctor - not something that a lot of family doctors do, but I was lucky to be part of an amazing call group where we shared the load, worked on 24 hour shifts and made it very doable for all of us. So there is - so in my first few years as a staff, I remember being called in right at the shift change, which was eight o'clock in the morning , by a staff who was quite senior to me. She had taught me a lot of what I knew and someone I have a great amount of respect for. So she said "Nadine, I'm very close to delivering, but it's not going to be done by eight o'clock. Do you mind coming in?" And I said, "of course I'll be there." And so I arrived and I turned to my colleague and said, "well, I'm here now. You're good to go. I'm sure you have other things to do - maybe you have a clinic or you have to be somewhere else." And she said, "no, if it's okay, I'd like to stay." And I said, "okay, that's interesting." She said "it's just been a really long night and I'm quite tired. I feel very much part of this delivery, but I don't feel like I can go through with the mechanics of actually delivering this baby because I am too tired." And I said - I thought to myself, Oh, that's different. No one ever says that. And I thought to myself even further, I don't think I can relate to that. I don't think I would ever say that. But kudos to her for recognizing it. And the day went on, we finished the delivery, everything went well, everyone felt good. Life went on. So it's only in retrospect that that story comes back to me because over the next - I want to say somewhere between five and seven years, because I've completely lost track of dates at this time - I did become tired and I did express that in very different ways. I might not have admitted it, but I was tired to my family. I was tired in my practice. I was finding that a day in the office would wipe me out in ways that I just wasn't familiar with. And that's when I kind of looked at the entirely of the land and realized, you know, something has got to give.

Dr. Rezmovitz 7:32

So what gave?

Dr. Laraya 7:37

So I had to look at everything and that's when I realized that we're not super human. And when we talk about wellness - especially in the type of messaging that we're getting as physicians - it's often about adding something in to the week: adding in exercise classes or adding in yoga or adding in mindfulness meditation workshops or what have you. And I just looked at the number of hours I had available and I thought to myself, you know, nothing's getting added in here. Something actually has to go away. And right now, what's being sacrificed is sleep and what's being sacrificed is quality time with people I enjoy spending quality time with - friends and family.

Dr. Rezmovitz 8:25

So was there one particular thing that you realized this? Do you remember the day that you said, you know what, I'm gonna make a change, and then what happened after that?

Dr. Laraya 8:39

So the decision ultimately to let go of a piece of my career that was so dear to me came over a period of time and the actual flip happened when the stars kind of aligned and I was able to finally make that cost benefit analysis and make the leaps. So over the course of a summer, I started really thinking out all the different elements of my life: thinking about the self care piece, thinking about the private practice piece, thinking about the on-call piece. And I went through a very calculated process and realized that there were diminishing returns to this piece that I was putting so much of myself into. I loved it and I still love it. You know there's almost nothing better than being involved in the birth of a baby and being part of that life event for - particularly if it's a patient in your own practice. I mean, those are moments that I will never forget and those have shaped me as a physician, plus just the technicality and the adrenaline of being on the delivery ward is something that was just so meaningful for me. But as time went by - my husband affectionately calls it, the blast radius - of being on call was starting to catch up and it was causing me to function less in every other aspect of my life. And when I looked at it, really the only reason I was hanging onto it was because of this identity of wanting to be that doctor who did a little bit of everything and could do this job. And part of it was ego-driven too . We had this narrative when we go through training that not everybody can stay up for 24 hours and then do a full day in clinic. And I was that person for a really long time and I didn't even realize it was catching up with me until it finally did. And we hear a lot about the word burnout and I'm not sure if I got there, but I might have. I might've stepped back just in time, but I had to look at what was not serving me anymore career-wise. And after a very long deliberation that went over months, I finally decided it's got to go and let's refocus.

Dr. Rezmovitz 11:28

And so you've given up being on call for OB - for deliveries or did you switch to a hard call?

Dr. Laraya 11:38

No, no. I gave up being on call at all. So what I was able to reclaim in doing that was something that I never thought was part of a physician's identity, which was to quote, just do a day job and be in my clinic. At first I felt like there was a bit of an emptiness and I didn't know what to do with it. But then I realized that all of a sudden I had this time and I had this space that I've never really experienced before. And you know, I was able to sleep every night without having to worry about a pager going off. And I wasn't either preparing for call or recovering from call - every night was just the same and that wasn't a bad thing. And I found that I almost felt at first that I was apologizing for the fact that I wasn't pushing myself to the max. And it took a little while, but I finally got over it and finally realized that, you know, we're all human beings and there is a major cost to pushing yourself to the max like that. And no one is forcing you to do that. And that's another point that comes up about being a physician is that you spend a lot of time training at a very high work demand level and you get used to it. You get used to doing a lot of stuff that nobody else would do. Sure it's rewarding, but man, is it ever tiring. Then you graduate and pretty much start the same patterns again because no one is telling you not to. And in family medicine in Ontario today - which is more my point of reference - there's no management around it. You can pretty much work as much or as little as you want to and no one is telling you you're doing too much or you're doing too little. The onus is really on yourself as a doctor to figure out where your balance is. And it's a tough place to be. It's tough to be in that in between world where you're trying to make a living, you're paying for your infrastructure and you're trying to keep your staff employed and you're trying to make something with this degree you've invested so much in, but at the same time you're doing essential services for the people of Ontario and there is really nothing by way of safety net that's going to catch you if you fall. If you burn out, it's on you. You know, there's no sick time. There's stress leave, there's no paid vacation. There's no lunch hour even mandated. So if you want those things available and you value those things, you've got to put them into place yourself.

Dr. Rezmovitz 15:05

Yeah, you really have to carve out the life that you want. And it takes time to carve that out. I had a similar experience in emerge and I gave up emerge because everything was pre-shift and post-shift. And I said, you know, I can't do this anymore. It's not part of what I want to be as a physician. And even being on call for the number of years that I was on call - have you heard about the new DSM 5 P that came out? The part that's just for physicians where it has the PTPD. Do you know about post-traumatic pager disorder? It's terrible because you have this like, "Oh my God, what is going on here?" And so I had switched three years ago - I switched my pager to my cell phone so that at least sometimes when the phone goes off, it could be somebody offering me like kind, thoughtful comments instead of just needing something all the time. Whereas with the pager, it was always like this need and when it goes off - oh my God, this catecholamine like rush that just drives the neurotransmitters in my brain to like want to shut down. It's terrible. What do we do to ourselves as physicians? But I'm curious , you said that not very often do we subtract things from our life and so you subtracted something and you said something that piqued my interest . You said, "now I had all this time." So what did you add in?

Dr. Laraya 16:44

So I was able to add in a number of things eventually over time because I would say that for the first year or so where I was back to a normal working schedule, where I could focus on my clinic patients and focus on being a great family doctor to that group of people. I focused on getting a healthier sleep schedule back because that's something that I hadn't known probably since the early 2000s. And that was a game changer for me because finally I was no longer running around, exhausted all the time and trying to function on somewhere between on average four and six hours of sleep every night. So that was huge. And then slowly I was able to do all the things that I tell all of my patients they need to make time for. So the exercise piece that was happening very sporadically for me over a period of three years became a three to five day a week no option habit. So it was routine, and it's a huge part of my life now. I was able to spend much more quality time with my kids. And in fact, one of the indicators to me that I'd made the right decision was a few months later, my daughter and I were chatting and she said, "remember those days where you used to disappear on the weekends and you'd be at the hospital, and sometimes you'd stay over and sometimes you'd come home for a bit, but then you'd go right back again?" And I said, "yep." And she said, "I hope you really loved that because I really hated it." And that to me was really telling that even my kids were picking up on the way that call was affecting my interactions. So the other thing that happened over the next year, so once the sleep and the physical routine was back and I felt that there is an initial balance, was that I was able to bring something into my life that I would never have had time to do with the type of schedule that I was managing. And that was to take on a job at the higher level of the hospital. And right now I'm the community family medicine liaison for St. Joe's, which is a hospital I maintain an affiliation with, which means that I get to be the person who communicates with all the doctors in the West Toronto area and the hospital, and I basically troubleshoot back and forth. And I'm able to get the feedback from our community to help figure out what the hospitals can and should do better, and figure out how the hospital can serve the doctors practicing in the community so that the information flow goes both ways. And it's been incredibly satisfying to be able to learn about how the hospital works in the bigger picture and to be a point person for individuals working in our community who previously didn't really have a connection. To be the person who, a doctor practicing a little further out West - maybe not close to where I am, but still in the community - can ask why a certain thing is happening or why a particular communication happens the way it does. And if I have this problem with this department, who do I talk to? It's a bit of an ombudsperson role, but it's really allowed me to get into understanding how the bigger healthcare system works.

Dr. Rezmovitz 20:43

So I want to thank you for coming on the show. Nadine Laraya rhymes with papaya, as you've told me. Do you have any parting words? If only they knew? Something that you can empower your younger self -what would you tell your younger self?

Dr. Laraya 21:01

It's okay to pace yourself. You don't - if you're driving along a road and you're accelerating and there are speed bumps, you might be accelerating and making great time on those times in between. But as soon as you hit a speed bump, you might fly off the wheel. So it helps to just take an even pace so that when those speed bumps come at you, you can take them in stride. So achieving balance in this world of unregulated, unmanaged world of community, family medicine, it's so important to know that what you do is enough. You can take good care of your patients and you can take good care of yourself and you can sleep at night. And if you can do all that well then you're contributing to the system. And you don't have to work yourself to the bone because you think that that is a part of what a doctor looks like. You're allowed to have a good life. And you know, one day I hope we'll have a system that recognizes that and compensates for that because right now there's not a whole lot that will inspire people to take that approach because as long as we work in a volume based system, there will be an overriding need and desire to work as much as you humanly can. Whether it's to make as much money as you can or to be the most productive person in the system or to serve as many people as you can. It's just so important to let go of at least one of those things so that you can stay in the system longer. Basically creating for yourself a life that you don't have to routinely escape from. One that's steady, even paced, that has the breaks built in, that has the sick days built in , that are there for you when you need them. Just to end with one last sort of anecdote if that's okay . I had a couple of weeks ago - I was really sick. I woke up in the morning and I knew that there is no way that I could go and be in contact with other human beings. It was just one of those really rapid onset gastro situations that I won't go into details about, but I couldn't be at work. So you work in community practice and as you know, there's no sick days. You can't just call in sick. There isn't going to be a substitute doctor who comes in and sees your patients. So it is a big deal to call in in the morning and to go through that process of saying, "you know, I can't do it today." Someone is going to have to spend the next two hours calling 25 people and telling them they're out of luck, and that we have to cancel their appointments. And that's g oing t o be a lot of work for a lot of other people so that I get to stay home and take care of myself and secondarily not in fact other people. So that was really in some ways a very challenging cost benefit to go through. It's sad to say, but we all do that. And that's probably a reason why a lot of doctors e nd up going to work sick because sometimes the balance just doesn't end up so clear.

Dr. Rezmovitz 24:42

And also because in a volume based system, you generate repeat business.

Dr. Laraya 24:47

Well, exactly, exactly.

Dr. Rezmovitz 24:49

By giving them the infection.

Dr. Laraya 24:50

Yeah, that's right. So I had to cancel a full day and that hurt - that hurt a lot. You know, it hurt me. It hurt, to an extent, my front staff. So this was not a decision that I took lightly, but I had to because it was the right thing to do. But I was so lucky that the way my week plays out, that there was space and I was able to spend - because I was in a good baseline space - well rested, fortunate to have good health. It took me 36 hours - actually, I had to take another day off the next day. And I didn't feel guilty. I didn't feel apologetic. I was grateful to everyone who stepped in and helped out. But because I had space in the schedule designed, I was able to move some of those patients into spaces that would have just been sort of vacant zones. And catching up wasn't a major issue. By the end of the week, I was caught up. By the end of the following week, I'd kind of made up the patient appointments and really it was a wash in the end. But to be able to recognize that my body needed a couple of days off and to have the support to do that and to not feel guilty about it, that was a very, very far cry from the apologetic, groveling nature I had to take when I had to explain to my call group at 32 weeks pregnant that I just couldn't do call a nymore and please forgive me. This is a terrible thing. That really - it was my own view. It had actually nothing to do with what my call colleagues thought, but I really felt like I couldn't that time. T hat I wasn't allowed to. So basically create space in your life so that you can stay in the game for longer because family medicine's a beautiful job. You get to do so many things and you can be part of so many amazing parts of people's journeys. But it's a lot less fun when you do - when you're run into the ground and when you're burned out and you're taking on more of an emotional and more of a cognitive load, t hen you probably should. So one day I'm hoping that the system will recognize that and make it easier to do that.

Dr. Rezmovitz 27:27

It's ironic that we as purveyors of health support our patient population and write notes for rest and stress leave and trying to improve the health of our patients, and yet we as a group, don't tend to leave enough contingency plans - space - for the stuff that might happen. So when it does happen, we are left burning out. So you get burnt out and then there's no space to - there's no - as you made the driving comment earlier - there's no shoulder to pull over to the side. You know, we're driving down the road in this fast paced highway and always feel the need to catch up or because somebody behind you is - so you feel like you need to prove yourself to somebody, but it turns out you don't. You don't have to prove yourself to anybody. And most importantly, the lesson from this is that, you know what, make sure there's a shoulder on the road that you're driving on so that if you need to pull over, pull over. So that there's space so that you can regroup and then get back on the road. I want to thank you so much for coming in today and sharing your story. It had a profound impact on me and I'm sure it'll have a profound impact on our listeners. I look forward to the feedback and thank you again.

Dr. Laraya 28:53

Thanks so much for having me Jeremy. It's great to talk to you.

Dr. Rezmovitz 28:55

Have a great day.

Dr. Laraya 28:56

Thanks.

Dr. Rezmovitz 28:59

This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullin, Brian Da Silva , and the whole podcast committee. Thanks for tuning in. See you next time.