Small Changes Big Impact
Small Changes Big Impact
Finding time to recharge your soul and empathy as a transformative experience with Dr. Diana Toubassi
In studio today, we have Diana Toubassi, family physician at Toronto Western Hospital and assistant professor at the University of Toronto. Today's episode focuses on the importance of finding time to recharge your soul and empathy as a transformative experience.
Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Diana Toubassi, family physician at Toronto Western Hospital and assistant professor at the University of Toronto. Today's episode focuses on the importance of finding time to recharge your soul. I hope you enjoy the show. So welcome. So I don't know if you've read the article recently, but I had a chance to read the Walrus article.
Dr. Toubassi:Oh boy.
Dr. Rezmovitz:And what I thought was interesting was I actually taught at that atelier and I didn't get a chance to see you there.
Dr. Toubassi:I know that was an unfortunate.
Dr. Rezmovitz:But it did have an impact on your life.
Dr. Toubassi:It did have an impact on my life, I would say. Yes, it did.
Dr. Rezmovitz:Can you talk about narrative medicine at all?
Dr. Toubassi:Absolutely. So I think that- I signed up for that atelier mostly out of curiosity. I think I was sort of reaching the inevitable sort of mid career point of re-evaluation that most of us do. You know, you sort of spend the first 10 to 15 years of your career mastering the clinical skills that you need to developing your teaching portfolio. And in my case, I had had lots of responsibilities and sort of locally in our unit I was the director of postgrad for many years and it was a challenging number of years for a number of reasons. And I think I sort of got to the point where I was starting to think about what would be next for me career wise. And I've always been interested in the humanities and in literature in particular. And so when this atelier came across my inbox, I sort of thought,'well, this would be sort of an interesting thing to explore.' And I have to say, I think that for me, the reason that it ended up being such a poignant experience was because it was an unusual moment to actually stop and contemplate things from a big picture point of view- which is something that we obviously don't get to do much of as family doctors. So I think that was sort of the first a-ha moment was,'Oh my gosh, I get to have like three or four days where nobody's going to ask for my input on patient care.' I'm not going to teach anything. I'm just actually going to be allowed to sit back and listen to these stories and think about things in a completely different way.
Dr. Rezmovitz:So please can you expand on the a-ha moment and the big picture that you just referenced?
Dr. Toubassi:I mean, I think that when you are able to step out of the daily- step off of the daily treadmill- you know, sort of the chronic hassles that everybody has to deal with in their daily life, the system issues that we all struggled with as family doctors that sort of day after day kind of leave you feeling often quite demoralized and discouraged. When you step away from that even for a few days and read poetry, or listen to other people tell their stories of their most meaningful patient encounters, I think it gives you- the distance gives you perspective, and compels you to think about what you want the next chapter of your career to look like.
Dr. Rezmovitz:You know, it begs the question, what is the next chapter of your career look like?
Dr. Toubassi:I think- so let me back up a bit. I would say that when I was younger- when I was a teenager or early years of university, I was very much into creative writing. It was something that I was always very interested in trying. And regardless of whether or not I was any good at it, it was something that I really enjoy doing. And I think as you get older you learn to put those types of interests and passions aside in lieu of more responsible adult enterprises like going into medicine and trying to be useful to your community in some way. And I think that turning 40 was for me a bit of a wake up call because I realized that if I wasn't going to start doing more of those things, that I was probably never going to go back to doing those things. And so I want those things to be part of the next stage of my career. So it's not just in quotation marks going to be about satisfying the masters of sort of the clinical world, the academic world, et cetera. It's also going to be about how do I feed my own soul.
Dr. Rezmovitz:Wow. So how do you feed your own soul? I mean, these are deep questions and maybe you can't answer how you feed your soul on a monthly or a yearly basis, but maybe there's a small thing that you do everyday now that helps feed your soul.
Dr. Toubassi:I mean, I know this sounds very sort of trite and you know, it's something that people commonly say, but to me silence is very important. Having solitude is very important. I think when you're an introvert, family medicine can be a very challenging way to practice. If you just even think about the number of people that you say hello to every day, the number of patients in clinic that you make small talk with before and after you deal with their medical issues, that is exhausting for somebody that left to her own devices would probably speak to like maybe two people in the span of 24 hours. So I have to have some way of sort of refilling the well and for me that is being alone and quiet. So I know that that's something that people talk about often- sort of the meditative benefits of spending time alone and reflecting on your own thoughts. But I've sort of come to realize after like 10 plus years in practice that it's not really an option as much as it is a necessity.
Dr. Rezmovitz:Yeah. You're not alone. You're definitely not alone as being an introvert. There's a book by Susan Cain- I think Quiet- and she goes on to describe the differences between extrovert and introvert and how we regenerate is really the metric on how to tell whether or not you're an introvert or-
Dr. Toubassi:Absolutely.
Dr. Rezmovitz:And probably wouldn't know this by looking at me, but I'm more introverted than extra.
Speaker 2:I'm not surprised. I mean, I think that people often think that if you have, let's say introverted tendencies, then you must be that way constantly, 24 hours a day, et cetera. But the truth is we all have like the ability to adapt to our situation as well. I suspect the majority of my patients would not say that I was an introvert because I turn it on when I'm in clinic with them.
Dr. Rezmovitz:Yeah. Tell me about it. I've turned it on for awhile now. Sometimes it feels like it's 24 hours, but then you're exhausted.
Dr. Toubassi:Absolutely.
Dr. Rezmovitz:Just emotionally drained.
Dr. Toubassi:Yeah. And so do that for 10 or 15 years and then see how you feel at the end of that. You know, and I think that's something we don't often talk about.
Dr. Rezmovitz:It's true. You know, most people who are introverted- again, this is assuming the metric that Susan Cain brings with- but if you're introverted and you're seeing all of that emotional- what's the word? Capital, I guess, right? Like it is exhausting. If you do that for 10 to 15 years, you might end up burnt out.
Dr. Toubassi:Yup. That sounds familiar.
Dr. Rezmovitz:Did that happen to you?
Dr. Toubassi:Yeah, I absolutely, it happened to me. I mean, I think even if you're an extrovert, coming up against the challenges of our system will often leave you feeling burned out. But I think when you add on top of that sort of the emotional cost of having to engage at a very deep level with patients and with learners it leaves very little at the end of the day.
Dr. Rezmovitz:But that's a choice. You chose to engage deeply with patients and learners. You could be like some other physicians in our province who don't engage deeply with people. But that's a choice that you made. And so the question begs is, why did you make that choice? Which probably is a reflection of how much you care and the enthusiasm and passion that you bring to this profession.
Dr. Toubassi:Oh, I hope so. Thank you. But I think that it would be a bit arrogant of me to claim that that was a choice. I think that that's probably also a temperamental feature. I think that if you want it depends what your view of success is, I think at the end of the day. And if your view of success is, I touched somebody today, I helped somebody today in a small way, that person's life is a tiny, tiny bit better because we spent 10 or 15 minutes together, then that's what's going to drive you. And I'm not sure that that's a choice so much as that it's sort of just a general inclination of your personality.
Dr. Rezmovitz:And you don't think that's a choice? You don't think you've trained it? You don't think you've had exposure and the amount of touches- I want to say touches- like number of encounters over and over again that you've said,'you know what, this is a part of me'? So it's almost- although you're saying it's not a choice, you've trained this so many times. You say,'this is what I need to do.' It's who you are.
Dr. Toubassi:Well, it's who you are. Yeah.
Dr. Rezmovitz:Because it's a choice. Because you've taken the last 40 years of your life- I mean, you, 40. Me, 25. And you've learned over a succession that this is what you like, but you're choosing over and over again because you get rewarded that when you engage with your patients, there is a reward. When you go to a certain level with your patients, when you advocate at a certain level with your learners, when you spent extra time- and time might be your surrogate marker here you get rewarded. And so it's a choice because I guarantee you you've had experiences with patients and learners that have been less than optimal and you say,'did I make a difference?'
Dr. Toubassi:Yeah. I mean, I think the physicians that you talked about earlier who have"made the choice to not do that," does that mean that they did not get the reward? I mean, I think if you are innately sort of a more attentive, empathic person, you're more likely to more deeply experience the suffering of the people around you, then it's going to be your natural inclination to try to alleviate that. Of course, that comes with all the downfalls of empathy that are now being discussed more in the literature, which is that at some point empathy becomes destructive rather than helpful. And it's better to sort of try to approach the work using sort of a general altruistic approach, but not so much where you're directly experiencing the emotions of the people that you're working with.
Dr. Rezmovitz:Yeah. There was a time when countertransference was a terrible thing.
Dr. Toubassi:Yeah.
Dr. Rezmovitz:And it's like, well, maybe it's not. Maybe you're invested. You find yourself invested, but now obviously if you're invested, that comes at a price to your emotional state- to the energy that you have that you can give.
Dr. Toubassi:Yeah. I think I would say that countertransference isn't sort of inherently a negative thing. It's just something to be aware of, and to try to sort of deliberately navigate. Probably- this was about a year ago now, maybe a little bit less than that- there was this lovely family in my practice who I've been looking after for a number of years. A husband and wife and their two sons. And the older son who was about 12 at the time came into clinic and basically presented with what sounded like a benign headache. And to cut a long story short, after sort of doing a history and physical exam, the nurse practitioner actually who was working with me that day, who had seen the patients, said there's something terribly wrong here, we need to send them for urgent imaging. And to cut a long story short, the boy was ultimately diagnosed with a cerebellar tumor. And this happened about a week before I was due to go on vacation with my kids. We had this trip planned to Florida and I just sort of had this moment of thinking to myself like, how am I going to leave this family? They were admitted to Sick Kids. They were waiting for radiation therapy. They didn't know anybody there. I went and I visited them at Sick Kids and sort of the look on their face of like,'Oh my gosh'- it's the familiar comfort of somebody that we know. And I think I thought about them the entire week that I was on vacation. So we would go to the beach and my boys would go to the pool and then I would walk up and down the shoreline and I would think about this young boy and his family and what they were going through. And I think you can easily hold that up as an example of how empathy can be destructive and how it can sort of invade your personal life. But to me it was nothing like that at all. It was actually an incredibly positive and transformative experience because I realized in the reaction of the parents when I went to visit them in the hospital, that we actually had something meaningful. Like our relationship mattered to them. It was important to them, it was helpful to them. And even though I wasn't going to be the person who was going to administer radiation to this kid, that my presence and involvement there actually meant something useful to them. So I sort of go back to that moment because to me it's a classic example of how when we talk to our medical students about the pitfalls of empathy, we say,'well this is the kind of thing you want to avoid. You don't want to be on vacation with your children thinking about your patients and how they're suffering.' But it was not like that at all for me. I felt like an immense privilege and almost like a sanctity about that experience that I- and in many ways like I credit that family- I've talked to them about this since- with bringing me back. Bringing me back to what is meaningful about our jobs as family doctors and why I want to continue doing the work that I'm doing despite all of the hassles that we have to deal with day after day.
Dr. Rezmovitz:So who said that it was destructive? That's what I don't understand.
Dr. Toubassi:Well, I mean I think view it as something that is emotionally costly. I think that if you are able to maintain a little bit more coolness to your clinical encounters- a little bit more distance, you, you feel less of the pain. There's no doubt about that. But you also feel less of the reward, I think.
Dr. Rezmovitz:I agree with that. But I don't think that it's- it's only destructive if it starts impacting the rest of your world. Right? Are you thinking about this family at a cost to your own family and then are aware of the cost and frustrated by the fact that it's costing you that time that you could have been thinking about something else? Only then is it destructive, but you obviously have a different perspective on it, which is great because it wasn't destructive at all.
Dr. Toubassi:No, it was the opposite of destructive. Yeah.
Dr. Rezmovitz:So why? I think that's a positive thing. And so I don't understand where this is coming from because I've also experienced that exact same thing. My wife has said,'where are you going?' You know, I had a patient who came in at Friday at six o'clock- because that's when patients come in- and having difficulty with his eyesight. And I said,'you know, something's off here.' We've got a CT. And they said,'well, who should I call when I get the results of this thing?' I said,'call me.''Really? You're going to be on call?''Yeah, just call me and I'll figure this out.' So he called me- the radiologist called me and he said,'we sent the patient down to emerge because there's a tumor.' And I said,'right, of course there is.' And so it was 11:30 at night and I couldn't sleep. And I said to my wife,'you know, I'm going to go to the emergency room. I'm going to go see him.' Because we had a relationship. And I showed up and they thought I was crazy. The patients thought I was crazy. I said,'has anyone told you what-' My first thing was'Hi.''Hi.''Has anyone told you what's going on?''Nobody.'.
Dr. Toubassi:Of course.
Dr. Rezmovitz:Three hours we've been sitting here- and I was deliberating back and forth, but I put the kids to bed and then I think something happened. Like I was trying to figure out what to do. I was early in my career and I went. And they appreciated it.
Dr. Toubassi:Yeah. You will never regret that you went.
Dr. Rezmovitz:Right. Yeah. Never regret laying eyes on the patient, right? And so it has a huge impact on your life. For you- so you went to the narrative- the atelier. And here we are telling patient stories now, and it's addictive and meaningful and part of who we are. And so what small change did you make every day that is- to regain part of your soul? That was the first question that I asked you.
Dr. Toubassi:Yeah. So yeah, I mean I think that I sort of mentioned the solitude and the silence. And I think that that's important. I think the other change that I made is to simply stop. So I am actually sort of- I'm on sabbatical at the moment. I've taken sabbatical from all of my clinical duties and the majority of my academic work to simply take a step back and reevaluate. And I think that that has been tremendously helpful to me. And I could not rec- despite the sort of bureaucratic hassle that it would be for people in charge- I could not recommend it more highly to everybody, every few years to actually stop and take a step back and think about where your career is. Is that what you want it to be? Are you doing the work that you want to do? Are you not doing the work that you don't want to do? Because those are two different things, although related. And is this what you want the next chapter to look like? Because I think it's not possible to do that kind of internal reflection when you are as consumed by the daily work as we all are.
Dr. Rezmovitz:Yeah, the grind is hard.
Dr. Toubassi:It's absolutely hard. Relentless.
Dr. Rezmovitz:So I think that's amazing. I've always contemplated whether or not we could create a system where- I think they have this in nursing where you take 80% of your paycheck over four years and then you get a 5th year break.
Dr. Toubassi:Absolutely. And teachers do this as well.
Dr. Rezmovitz:I would love that.
Dr. Toubassi:Yeah. And it's interesting to me that for some reason we haven't considered that to be an essential part of professional development in medicine. You know? I mean, my friends who are sort of in more- I would say in quotation marks,"pure academia"- who sort of work in the university, think nothing of taking a full year sabbatical where nothing is expected of them during that year. No academic output whatsoever. And yet somehow in medicine where we are engaged directly one-on-one in patients and their wellbeing, this is not something that we think of doing.
Dr. Rezmovitz:Yeah. You never, you're not allowed to stop.
Dr. Toubassi:You're not allowed to stop. You're a cog in the machine.
Dr. Rezmovitz:That's right. Yeah. It's really tough. So I'm so impressed that you took a sabbatical. I think it's amazing. If anyone wants to offer me a sabbatical, let me know. So what were the barriers you think to making this change in your life right now? The sabbatical?
Dr. Toubassi:I mean, expectation really was what it boils down to and it's the expectation of others. It's my own expectations. I mean, I think if you have established a career in medicine and you've done- I say this with some embarrassment, but you've done fairly well at it, it is confusing to people if you want to stop rather than continue to climb the hierarchy. And so, it's risky also because you wonder are you labeling yourself in some way that would make you a liability in the future? Okay. She's the person who turned down this position. She's the person who wanted to do less rather than more. We don't want to invite her to be on this committee. Don't give her that position because we don't know if she can be trusted to stay with it for the entire tenure of the role. So these things are- they weigh on you because you don't necessarily know what the next 10 years are going to look like and you might take a sabbatical and try writing and then discover that it's not what you really want to do. So there is risk to it. There's obviously also an impact on your patients, right? I mean, the reaction from my patients from being away from clinic for a few weeks only was just incredible. I mean validating- certainly validating, but just surprising to me how disruptive they felt it would be for them- for me to be away for a short period of time. Even if they weren't going to need necessarily to see me during that time. You know, I've had some of my patients say,'yeah, but we know you're there if we need you. So if you're not there, that creates anxiety for us.'.
Dr. Rezmovitz:You've created a security blanket.
Dr. Toubassi:Right, right.
Dr. Rezmovitz:It's hard walking away from that.
Dr. Toubassi:It's very, very hard. Yeah. And I mean other barriers- I mean, we all see ourselves in a certain way and it's very hard to kind of break out of that mold. So I think that's also something that I would need to take responsibility for. I mean, I stand in my own way as much as anybody else does, so.
Dr. Rezmovitz:No one's ever said that here before.
Dr. Toubassi:Really?
Dr. Rezmovitz:Yeah. That's amazing. When did you learn that?
Dr. Toubassi:It doesn't really strike me as something that needs to be learned. I'm a very strong advocate of personal responsibility for one's own life choices. And so I try to live by that rule.
Dr. Rezmovitz:Yeah. Ownership. It's amazing.
Dr. Toubassi:Yeah.
Dr. Rezmovitz:You know, I had a resident and I tried instilling ownership in the resident. And there was some resistance. Two years of resistance actually. Right?
Dr. Toubassi:Yeah.
Dr. Rezmovitz:And we bumped into each other a few years later. And he said to me,'actually, I didn't realize it until I left, but what you were trying to do was prepare me for the world.'
Dr. Toubassi:Absolutely. Gosh, absolutely.
Dr. Rezmovitz:'And here I was resisting this while I was a resident and taking ownership would have been the best thing I could have done to set me up for success.' Because you need to own what you do in this world of medicine that we practice. And whether or not you're a barrier to yourself- well, we all are barriers to ourselves, right? We all- it's that awareness to go,'what am I doing that is impeding my progress?'.
Dr. Toubassi:Absolutely.
Dr. Rezmovitz:'How do I better' And most people, most people like the hole that they're in and they're comfortable.
Dr. Toubassi:Absolutely. This is what makes change so difficult and terrifying for all of us is that if you are going to try to do something differently, it requires you to first admit that what you're currently doing is insufficient in some way. And that requires humility and that's what makes it so difficult. The first step is admitting that what you're doing is insufficient, wrong, inappropriate, just not meeting the standard in some way.
Dr. Rezmovitz:I should let you know.
Dr. Toubassi:Yeah.
Dr. Rezmovitz:I have a problem.
Dr. Toubassi:Tell me.
Dr. Rezmovitz:Oh, I just- that's the first step. Always.
Dr. Toubassi:Yeah. Yes, exactly. Admit that there is a problem. Admit it.
Dr. Rezmovitz:Yeah. You're trying to go back into your family doctor ways there. Remember you're on sabbatical.
Dr. Toubassi:You can't ever permanently turn it off.
Dr. Rezmovitz:Yeah. We're not gonna have you do that. You're on sabbatical. I'll be mindful and respectful of your sabbatical.
Dr. Toubassi:Thank you. I appreciate it.
Dr. Rezmovitz:So you don't have to listen to my problems this morning. As we come to a close here, let's talk about if they only knew. You know, I like that phrase. If they only knew. This is your opportunity to tell the world if they only knew, and it could be whichever world you want to talk about. It could be home, it could be a hospital, it could be the learners, it could be the patients. If they only knew.
Dr. Toubassi:How much better things could be if we looked within us rather than outside of us. If we came to ourselves first for the change, rather than expecting other people to do it for us. And if we stopped trying to fix the world by fixing other people, that's what I would say.
Dr. Rezmovitz:Amen. Thank you so much for coming in today. Really appreciate your time.
Dr. Toubassi:Thank you so much for the invitation. It was really fun.
Dr. Rezmovitz:Awesome. Have a great day. 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.