Doctors as patients and challenges with transitioning back to work with Dr. Tali Bogler

In studio today, we have Tali Bogler, a family physician at St. Michael's Hospital and Chair of family medicine obstetrics there. She's a lecturer in the Department of Family and Community Medicine and a yoga instructor and creator of Downward Docs. Today's episode focuses on doctors as patients and the integration required between the department and health care system. 

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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 Tali Bogler, a family physician at St. Michael's Hospital and Chair of family medicine obstetrics there. She's a lecturer in the Department of Family and Community Medicine and a yoga instructor and creator of Downward Docs. Today's episode focuses on doctors as patients and the integration required between the department and health care system. I hope you enjoy the show.

Dr. Bogler 0:38

Thanks for having me, Jeremy.

Dr. Rezmovitz 0:39

No problem. So let's talk. Tell us a little bit about yourself.

Dr. Bogler 0:44

Okay. So I'm a family physician as you said at St. Michael's Hospital. I did my family medicine training here at U of T, at St. Mike's. And then I did a one year fellowship in women's health also at U of T, and in that one year fellowship I did three months of obstetrics training. At the same time, I was doing my Masters of Science and Community Health here at U of T and then joined the St. Michael's Hospital family medicine practice, which I've been practicing at since 2015. And so I have a family medicine practice of my own there and I also do low risk OB. And I'm a mother of twin girls.

Dr. Rezmovitz 1:29

Wow. You sound busy.

Dr. Bogler 1:31

Yeah. Things are busy but good. Things are good and busy .

Dr. Rezmovitz 1:36

How do you manage all of that?

Dr. Bogler 1:38

Oh, that's a long answer.

Dr. Rezmovitz 1:40

We have time.

Dr. Bogler 1:45

I could say confidently that I am managing it now and I'm enjoying what I'm doing. It probably wasn't always like that, but through effective time management and setting priorities and all of those things that we're all trying to do to make time for everything in those different roles.

Dr. Rezmovitz 2:12

Like you were taught in medical school?

Dr. Bogler 2:13

Yeah. So -

Dr. Rezmovitz 2:18

You know what I was told in medical school? On the first day of medical school I was told there are 28 hours in the day. Use them all effectively.

Dr. Bogler 2:23

Exactly.

Dr. Rezmovitz 2:24

Right.

Dr. Bogler 2:25

Yeah. I have a supportive partner. We figured out how to take care of our kids, various strategies, life hacks that we've both sort of figured out over the years.

Dr. Rezmovitz 2:38

Was there one particular instance that was not good, as you alluded to? As things are better now, but was there one particular instance that you want to talk about?

Dr. Bogler 2:48

Yeah. It's - well, it's not a particular instance, I think. I guess sort of I've described my career trajectory sort of since 2015, and at the same time I was also starting my family personal life, right? So that was all happening around the same time and that's hard. So while I was building my practice, I was also getting married and thinking about starting a family. Basically i t was pregnant with twins quite quickly. So in 2016 and it was an exciting time and I was still building my practice, but I think the big challenge that happened to me in those first few years of starting my practice was sort of the medical complications that come with being pregnant with twins. I was suddenly, at 23 and a half weeks pregnant, had to go on sudden b ed rest because I was at risk of preterm labor - significant risk. And although I practice obstetrics and counsel patients on the risks of twin pregnancies and w hatnot, I was - I found myself in a situation where I had to suddenly just stop work a ltogether a t 23 and a half weeks, and go on "bed r est". And with that came lots of challenges, both obviously just the anxiety of having premature children and what that would do to my relationship and my husband and our families, but also then the work challenges of suddenly having to stop family practice - I had just built this practice. How do I find a locum? What are the financial implications of all of that? And sort of navigating that almost alone. And it was a very stressful time for me. There were financial implications of just suddenly stopping work - I'm part of a relatively large department and there's policies in place about what happens when you suddenly stop work and I lost some money in that process, and getting emails about sort of the policies and perhaps emails without people really reaching out to actually call me and ask me how I was doing on a personal level. So I really struggled with that. And I mean, I'm not g oing t o get into the specifics of all of that because I think you could imagine at any big institution there's going to be policies, but I really did struggle with that leave and t hat transition. For example, at St. Mike's we have a parental leave policy, but we don't have a medical leave policy. So I really didn't - I wasn't eligible for disability. So there's impacts to all of that and it's very stressful trying to navigate both your own personal life and going on l eave suddenly - so sort of the medical leaves associated with pregnancy. I went into premature labor at around 34 weeks - it was an emergency Cesarean section, a nd my girls were in the NICU for just over a month. It was - obviously having twins, bedrest, the prematurity, the NICU, all of that obviously was, a s you said, a challenging time for me. As much as I've experienced the NICU as a trainee - I do obstetrics - it was the physical and emotional, psychological intensity of all of it. It was just a very intense time in my life and actually, I didn't really feel like a family doctor at the time. I really separated those two. Those two parts of my life became quite separate. An d I think the challenge was figuring out how I would ever transition back to work.

Dr. Rezmovitz 7:19

You sound like a patient.

Dr. Bogler 7:21

In what sense?

7:22

Like it's real. Like it's hard being a patient.

Dr. Bogler 7:26

Oh.

Dr. Rezmovitz 7:26

You said it - you weren't a family doctor because you were a patient.

Dr. Bogler 7:31

Right.

Dr. Rezmovitz 7:31

It's hard being a patient, navigating the system, let alone being a family doctor, trying to navigate and advocate for our patients. Sometimes it's hard to be a patient, but we've all been patients. We tend to be human, most of us. I haven't met any superhuman doctors yet, but I know that it can be very difficult navigating the system as a patient because you know certain things.

Dr. Bogler 7:56

Yeah. Yeah.

Dr. Rezmovitz 7:58

And so it can be overwhelming. You had a lot of challenges.

Dr. Bogler 8:02

Yeah, there were a lot. I actually physically and mentally did quite well in the NICU. I was - I managed to breastfeed my twins and figure it out and I was doing quite well. And it was actually only months after when I started to reflect on the whole experience and thinking about going back to work that I started to realize things aren't as well as I thought they were?

Dr. Rezmovitz 8:34

In what sense?

Dr. Bogler 8:36

Well, I was extremely nervous about going back to work. I just couldn't imagine with all the responsibilities I had at home with twins and feeding and caring for them. How in the world could I go back and be a physician? Like there's just - it's just not possible. Like I don't have enough time. I don't have enough energy to be able to do that. I was extremely anxious about going back to work. I felt because my leave was very stressful and there were all these policies I had to navigate and all of that. I also felt a little bit not as excited about going back to work. I think it just was a very trying time for me. Maybe perhaps more than - I know lots of women and lots of parents - it's not always an easy time being on parental leave. People kind of think about it as this great time: you can go for walks, you can go to the AGO with your baby. Well, it wasn't like that for me at all. I definitely felt that in the state that I was in, I didn't think I could go back to work.

Dr. Rezmovitz 9:51

So what happened ? How did you overcome that? Because obviously you overcame that.

Dr. Bogler 9:57

It's interesting because my husband who was very supportive actually said maybe you do need more time off of work. You went through a lot with bedrest and the NICU and really my parental leave started at 23 and a half weeks even though I hadn't delivered. So my parental leave was sort of shortened by the fact that it had started so early. And a lot had happened . I had infections with breastfeeding and all of that stuff. And he said, why don't you take more time off? Like, you don't need to go back to work. You should stay home with the girls. And it came from a very supportive place and then I was listening to him and then kind of thinking like, if I don't go back now, I imagine that it might just be harder. But realized, obviously I couldn't just jump back into work. I didn't feel - I was very anxious about it and so I sought out help. I sought out someone that I knew would just sort of get it, and I also opened up to our clinical lead and kind of told them about how anxious I was about returning to work and whatnot. And she was very supportive, our chief was supportive. And I think it was just recognizing that [I] probably did need help and talking - just being open about it with the people that maybe I probably would have never thought I would be open about it in the first place, and having someone to talk to about it that just got it, really helped me transition back to work. I set limitations. Like, I didn't go back to obstetrics right away and I was open about that with the OB team. Like I said I'm not ready to come straight back to obstetrics. I want to get my feet wet, go back to family medicine and then slowly integrate obstetrics back into my practice. Even my schedule, having a little bit more flexibility on when I would be with learners and whatnot in terms of the afternoons , and getting back to my kids. So I found that support to transition back.

Dr. Rezmovitz 12:21

So how did this impact - have you noticed your choices? How did your choices impact either an experience with a learner or an experience with a patient afterwards?

Dr. Bogler 12:34

It's impacted me in so many ways. I think first of all, this whole experience has definitely made me a much better physician - a more compassionate physician, especially in the areas of like women's health, which is a focus of mine. And part of that, part of me feeling that I am a better physician because of all of this, has made me enjoy work so much more. So I just delivered a week ago , a woman and her partner at 34 weeks - I delivered their baby girl. And the other obstetrician that was in the room was the one who did my delivery. So we're all in the room together and she's worried that she's delivering at 34 weeks, which is exactly the same time that I delivered. And boy did I get what she was going through. And we formed this connection. I could tell - like I reassured her, I knew exactly what her fears were. I really supported her in that labour. It was a beautiful delivery. The baby's healthy - the baby's still in the NICU, but I go visit them and I get it. Like I get what's going on in the NICU. I get what it means to have your baby transferred from the incubator to a bassinet . Like what an achievement that is. I did not understand that before. Like incubator to bassinet - what's the big deal. But it's a huge deal. And I could see that they were excited, that I was excited for them. So it's made - and that's just one example. But in terms of all my patients and the struggles that they have with getting their babies to sleep and breastfeeding and -

Dr. Rezmovitz 14:30

People have difficulty getting their babies to sleep?

Dr. Bogler 14:33

I get it now. I get it, and I thought I understood it before, but I really get it now. And I think it's made me enjoy work so much more. I actually love going to work.

Dr. Rezmovitz 14:51

That's amazing. I told someone once - at no point did I think this was actually going to ever happen, but I felt it was imperative for family doctors to spend a lot of time with children - trying to put them to sleep, trying to get them to do things , before they could offer advice on how to parent. Because it boggles my mind how people can offer advice on something they've never had. Although if you look at what we do as family physicians, I don't have rheumatoid arthritis, but I counsel people on rheumatoid arthritis. I don't have spinal stenosis, but I counsel people on what to do. So I see it on both sides.

Dr. Bogler 15:29

I agree. I agree. It just happens to be that my focus has been on women's health even before all of this. And now that I've experienced both complications of pregnancy and - it just has made me a better doctor. I don't think I was a bad doctor before, but it's made me able to relate to patients a bit more and just get it and be there for them a bit more. And I have a little bit more knowledge and insight.

Dr. Rezmovitz 15:56

So that's really impactful with patient care - caring and having compassion for what people are going through. I mean, that's the definition of empathy. You were given the gift of crisis, if you will. You know, you went through this crisis, but on the other side you can see all the positive aspects that come out of what you learned from there so that you can then give it to other people.

Dr. Bogler 16:19

Right. And I think I can say that now because I feel good and I'm happy and I'm loving work. I don't know how I would have answered these questions while I was sort of in the middle of my parental leave right? When I didn't even see myself as a doctor anymore.

Dr. Rezmovitz 16:36

That must been tough. So how did you get - what did you do to redefine yourself as a physician?

Dr. Bogler 16:44

I didn't redefine myself. I think just going back to work was probably one of the best things that I could have done for myself because I don't think I realized how much of an identity being being a physician was to me. Like when my husband was saying maybe just don't go back to work, I was like, yeah, I don't need to go back to work. And I didn't realize how important it was for me to be at work and get that fulfillment because it's a huge part of my identity. I just kind of -

Dr. Rezmovitz 17:15

So when did that happen? When did you realize that it was such a -

Dr. Bogler 17:19

I think within weeks of being back at work and enjoying seeing my patients and enjoying the interpersonal aspects of family medicine, the clinical aspects, I think just my pure enjoyment of being there and feeling good at what I was doing and knowing that I was doing a good job made me realize this is not something you can just sort of leave. I mean, you can, but it made me realize that no, this is not something I'm - even in the future, if something were to happen, I realize how important it is to me.

Dr. Rezmovitz 17:52

Why is having that identity so important to you? What is it about being a family doctor that is so - what's the word I'm looking for? That is so a part of your being? It was just - I'm listening to this and I'm thinking -

Dr. Bogler 18:08

What is it? What is it? Why is it so important to my identity?

Dr. Rezmovitz 18:12

Yeah.

Dr. Bogler 18:14

Well, I mean, maybe it's not my identity, but it's how much I enjoy it?

Dr. Rezmovitz 18:22

I don't know. How much do you enjoy going to work?

Dr. Bogler 18:26

I really do enjoy going to work. I mean , especially with the practice that I have, I have seen parents, women, their partners and their babies, and seeing them across that lifespan and supporting them as they're trying to conceive and then during their pregnancy and then being part of their labor story and then supporting them with breastfeeding and caring for their kids. Like I just feel like I'm making an impact on people's lives on a daily basis. And that is something I love to do. I feel very fortunate to be able to do that and it excites me.

Dr. Rezmovitz 19:15

That's amazing. You know, you hear so many doctors today who are shrouded in burnout in this culture of being overwhelmed. And it sounds like you are thriving.

Dr. Bogler 19:27

Right now.

Dr. Rezmovitz 19:28

Yeah of course. Right now. It's a spectrum. It goes from surviving to thriving. I mean in two hours, you could have a crisis.

Dr. Bogler 19:38

I think things are really good right now and I feel really fortunate because I was able to sort of recognize it, seek out the help, have a supportive partner and family members, have really good childcare, which is key because I feel like my kids are in good hands. But that's not always accessible to everyone. So I do feel fortunate that I was able to get past that really, really trying time and be where I am right now.

Dr. Rezmovitz 20:09

That's awesome. Have you spoken to any learners about this and their journey and how you could impact their journey?

Dr. Bogler 20:17

So I kind of kept it quiet a little bit in terms of how I was struggling when I was on leave. And you know, as most people do - are sort of only talking about it once they feel better, which is - it does a little bit of a disservice to - in terms of our goal to improve wellness in our culture in general. But I have to be honest, that's sort of what I did. So I didn't really tell people too much about my struggles except for the clinic lead and the chief. So I wasn't really so open about it and I still not really that open about it, which is why I'm surprised that I'm on this thing talking about it. But when the U of T medical school first years did a series on wellness and asked some of us if we wanted to talk about our experience, I decided to talk about it. And that was actually my very first time talking about it with - there about 20 to 30 medical students in a circle just listening to me. And I kinda like got nervous telling them about it. And I actually didn't really even know how they responded or reacted to my story because they were kind of silent.

Dr. Rezmovitz 21:35

Why do you think you were nervous?

Dr. Bogler 21:38

Look, there's still that stigma. It was hard for me to talk about it for my very first time without really talking about it in a public setting - at least within medicine. Even though the whole focus of that session was on wellness and burnout, I did feel - there's a level of sort of embarrassment that - whatever, even if we're not supposed to be embarrassed or it's just a natural feeling, talking about our own struggles with strangers, I guess?

Dr. Rezmovitz 22:11

I think there's unfortunately - we conflate weakness and being overwhelmed. Unfortunately our culture sets us up for opportunities to be overwhelmed because we excel at a lot of things. We as family physicians, we are capable. We are very capable people and we do this everyday . We support people every single day and sometimes we forget to support ourselves. And so it can be overwhelming when you're supporting that many people and you forget to support yourself and it takes its toll on you because it turns out we're human.

Dr. Bogler 22:53

Right. I think there's definitely that sense of - and speaking to other physicians about this topic - that it is a point of weakness if you're not able to sort of figure this out on your own. Of course, I know that's not what it is, but that's just sort of the natural sense that many people feel.

Dr. Rezmovitz 23:12

And we need to change that.

Dr. Bogler 23:13

Yeah. But anyways, those medical students have reached out to me - a couple asking to shadow me and talk to me more about their careers. And then I was asked to do a TED talk on wellness at some point later on. So there has been positive feedback about it, but it's not something I typically share with everyone generally.

Dr. Rezmovitz 23:35

Until now.

Dr. Bogler 23:37

Until now. Until this podcast. Yeah.

Dr. Rezmovitz 23:40

You might have more people reaching out to you. I mean, the fact is you're not alone.

Dr. Bogler 23:45

Right. And I think it's not just specific to medicine. I mean many women - and I have to say on that point, my experience is specific to me and being a woman and I know men have different struggles. Like there's - I was speaking to someone in our department that wasn't able to take proper parental leave because of certain policies from the OMA and how hard that was on him, or my husband when I went back to work and he would take the girls to certain groups and people would be like, where's their mom? You know? And so everyone has a different experience. So my story is specific to me and what I went through, but I know that everyone experiences transitions or parental leave differently.

Dr. Rezmovitz 24:32

No, of course. So what can we learn from today? Can you give us some parting words if you will , to either your younger self or to those on the journey that could help people learn from your struggles?

Dr. Bogler 24:49

Well, I think on a broader level I think there needs to be a bit more awareness in general on the first five years, first 10 years of physicians in their practice. And we can focus on family medicine for sure. But I think - I used to think that only after many years of working in family medicine, you would start to get burnt out. That was sort of my thought. Like you work a lot. It's too much. At some point you get burnt out. But it's actually not true. Right. So we know the, you know, the recent 2017 CMA national physician health survey, and that's when I think that's - hen I read the survey, I'm like, yeah, this makes sense. This is sort of what I was - this explains a little bit why it was so challenging for me.

Dr. Rezmovitz 25:41

Yeah, it's not a binary question anymore. It's not "are you burnt out?" It's "how many times have you been burnt out?"

Dr. Bogler 25:46

Right. But they found that physicians in the first five years have - after residency and medical training - they're the second group that has the highest levels of burnout, lower resiliency and higher suicide rates than physicians after 31 years of practice. So they have the highest levels, and I think it's a time that we kind of often maybe even like neglect as a - I don't know, neglect, but I think more awareness needs to be put on this these specific years.

Dr. Rezmovitz 26:16

Maybe it's a group of people that feel unprepared in their first five years for what is going on?

Dr. Bogler 26:23

Yeah . I think having maybe not such high resilience, maybe having these life changes, these transitions, which are, you know, huge for some people and might be less challenging than others, but it's a difficult time to be building your practice and transitioning off and then back to work and have maybe health issues that might be associated with pregnancies, parental leaves, whatever. So I think two things: I think at a department level, at an institutional level, there needs to be more awareness on how we can better support early career physicians, whether it's financial training , mentorship, more comprehensive parental leave so that we feel a bit better supported financially because we're still paying off debt from our medical training while all of this is happening. There's lots of stressors. Like it makes sense to me why burnout is higher in the early careers. It just - now having gotten through it and coming to the end of my first five years. And then I think on an individual level there's sort of adaptive strategies that you can take, which is sort of similar to what I did. And that's seeking out people that might've gone through a similar situation, finding those mentors that you feel like would be open to hearing what you're going through , seeking out help when you need it, and sort of setting boundaries and learning to say no, and coming back to work and finding that balance and maybe setting limitations and boundaries at first and then start to build up again.

Dr. Rezmovitz 28:13

Yeah. Learning to say no is a big one. But it's very hard because most people in medicine and most healthcare providers are genetically programmed to say yes.

Dr. Bogler 28:24

Right? But then I think I would look at it as maybe when I - I'm just taking transitions back to work and thinking about that and just thinking, you know, this is a temporary thing. I'm going to say no, just for the time being until I feel okay and then when you're ready, taking on more, which is kind of what I did. So I went back to obstetrics slowly and now I'm going to be the chair of obstetrics. But it wasn't all at once. That would have been a lot if I had come back from all of the experience that I had and just jumped right back into it. And I think as leaders within our institutions and departments, I think we need to really respect that and allow people to be flexible, especially when they're transitioning off and back onto work.

Dr. Rezmovitz 29:07

Totally agree. I want to thank you for coming in today. It was an enlightening conversation. I really hope other people will take from it and how you can overcome struggles and impact learners, patient care and yourself by taking time to ground yourself in who you are. So thank you so much.

Dr. Bogler 29:33

Thank you for having me.

Dr. Rezmovitz 29:37

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.