AOHC Encore 2023-126 Myths or Truths? Reviewing Common Ideas

126 Myths or Truths? Reviewing Common Ideas

Video Transcription

Well, good afternoon, everyone. I guess I'm going to get started, because it's 2.45, but I'm assuming that there may be some other people popping in and maybe out of the room.  My name is Quentin Durand-Moreau. As it sounds, I'm not from the US. I'm not even from Canada. I come from France.  I'm an occupational medicine specialist for the past 10 years, and I'm now working in Edmonton, in Alberta, for the past four years.  And I'm an assistant professor there and also the residency program director for the occupational medicine residency program. So it's Sunday afternoon.  It's been a long day in this conference, and we have the most motivated section of the audience willing to dive into fun topics such as depression and burnout on a Sunday.  Well, you have your hobbies, apparently. So I'm going to try to make this presentation a little bit engaging and fun and not being,  you know, a collection of slides with just, you know, data on it. So you're going to be so asleep that you can't participate to the opening ceremony afterwards.  No, I'm going to try to keep you awake. Before I get started, I do have a couple of, you know, usual disclosures.  I'd like to acknowledge that I'm coming from the University of Alberta, which is located  on what we call Treaty 6 territory, a traditional gathering place for diverse indigenous people,  including the Cree, Blackfoot, Métis, Nakota Sioux, Iroquois, Dene, Ojibwe, Saulteaux, Anishinaabe, Inuit, and many others whose histories, languages, and cultures continue  to influence our vibrant community. My personal disclosures pertaining to this presentation, I do have some grants from the  Workers' Compensation Board of Alberta, some of which pertain to this presentation. I do a portion of my research on psychosocial risks, so I get some funding to do my research,  which makes, I hope, a little bit of sense. And I will report on some papers, and some of them come from a journal that you may know,  which is called OEM, which is not J-O-E-M, or the AECOM journal. OEM is another journal, Occupational and Environmental Medicine, and I'm an associate editor for this journal.  And I'm also having a leadership position in ICO, the International Commission on Occupational Health.  I am the co-chair of the Scientific Committee on Work, Organizational, and Psychosocial Factors. So these are the disclosures that are probably more relevant to this presentation.  So without further ado, I'd like to dive into five questions that we are going to review quickly.  We could spend a lot of time on each one of those questions, but I'm going to try to keep the speed a little bit fast, so you're still with me for the entire presentation.  And let's dive into the first one. Are psychosocial risks a new trend? Well, it depends on what we call new.  It certainly didn't appear over the past year or 10 years, probably a bit more than that.  But how far in the past should we go to find the first evidence of anyone having an interest in psychosocial risks?  Well, someone did a PhD, a colleague of me, in work sociology, and did a work around fatigue in healthcare workers, and published his PhD thesis in 2000.  And in his thesis, there was a very interesting historical section. And Marc L'Oreal, the sociologist, went as far as the 4th century, which is quite far away.  Well, so he found some texts. We can't really say evidence, because when it's so old, it's historical documentation rather than evidence.  But anyways, he mentioned some work from someone called Evagrius Ponticus, who died in 399. And this person described a phenomenon called ossidia.  And ossidia has been defined as an unnatural weakness of the soul which does not resist the temptation. What's interesting is that he described this phenomenon occurring in monks.  And he said, or we think that he said it was like dozens of centuries ago, the monk suffering from ossidia is non-challenged with praying. Sometimes he will not pray at all.  Remembering that monks were to be considered as workers at that time. But maybe the most interesting point of all of this is that not all monks were considered  to be equal with ossidia, this, you know, laziness, unwillingness to work, like kind of fatigue that we can say.  And it was mentioned that Cenobiacs were less concerned with ossidia than the others who were more secluded. Cenobiacs were living in communities.  So here is probably the very first description of evidence of any benefit of a social support.  Working in a group is probably a bit positive on mental health, as opposed to being in seclusion, very isolated.  So that's the very, like probably the oldest thing related to the links between work and health that have been documented in history. But fast forward to the 20th century.  As I told you a bit earlier, I come from France. And in France, there is a long tradition of work psychology of over a century.  So there's a lot of pieces and a lot of psychologists and also philosophers have worked on those questions. I want to mention one, who is this person on the slide, Simone Weil.  Simone Weil had a very fascinating story. She was a professor of philosophy, and she was working on many questions, including work.  And she was so engaged and involved in her work that at some point in her career, she decided to resign from academia, and she was hired as a blue collar worker in factories  so she could experience what it was to be working in a factory. And then it was, you know, some food for thought. And then she was able to work on those questions.  So she's been working in several factories, and she kept a diary on that. She did some journaling. She didn't publish the journal.  It was a very famous French author, Albert Camus, you may know of him. Albert Camus has published the diary 30 years afterwards from Simone Weil.  So thanks to Albert Camus, we know about it, because I'm not sure she had the project of publishing this.  But in her journal, in her diary, she kept all of her thoughts, all of the descriptions of what her work days were like, which provides really great information about the working  conditions at that time. So this is a small piece of her diary coming from the very first day she spent in the second factory she was working on, the Renault factory.  You know, the United States are very famous for the Ford cars, you know, Ford, Henry Ford, you know, all of this. In France, it's the Renault cars.  I guess there's no such cars in North America, no Renault. We don't have this in Canada either. Anyways, very famous in France.  And there was a factory located in the middle of La Seine, the Seine River. And you had to cross the river to access to this factory.  And she explains that after her very first day there, she had to cross it back. And she says this in her writing, despite my exhaustion after my first day there, I  need fresh air so much that I walk back to the Seine. Here I sit by the river on a rock, emotionally exhausted because of this powerless rage literally burned out.  In the case I would be condemned to live this life forever, I wonder whether I would be able to cross the Seine without throwing myself in. 1934.  Probably one of the most clear description of work-related societal faults that I've found so far.  So really early in the 20th century, there was already some psychosocial risk, already some people mentally struggling with work.  Fast forward to the last piece of evidence, or historical evidence, that psychosocial risks are not new. We are now in 1961.  Here from France, a book has been published called Overwhelmed Managers. Two professors of work psychology from a reputable institution in Paris have been writing this  book, Overwhelmed Managers, and they describe in this book why managers could be stressed and what they could do to sort it out and cope with the stress.  Actually it really looks like some books that we currently have in bookstores. Self-education tips, you know, those kind of books, questionnaires, do like this, do  like that, you know, self-education tips. Nothing new, like it's 60 years ago that we already had this kind of books.  So how to cope with the stress, including best practices to relax inspired by yogi, which is interesting if we put this in relation with the increased publication and work around  mindfulness which is also inspired by this kind of origins. So they mentioned a lot of causes of work-related stress. They are very political.  They mentioned the abusive fiscal pressures, unskilled collaborators. By the way, we are talking about managers.  So we are talking about the very one who hired those unskilled managers. So I would probably question their skills as managers.  If they complain about having unskilled collaborators, well, maybe you have to have better practices in terms of hiring.  But they also mentioned things that I didn't dare putting on the slides. One of them was women. They were complaining about women. I will probably give you a little bit of context.  We are talking about a book on psychosocial risks of managers in the 60s. So almost exclusively male, white male, having women at home that were bothering them with  kids, with things like all of this useless stuff related to household chores. And after a long day at work, the managers were getting overwhelmed because of the women  providing them with those comments on how the kids were doing at school or financial problems in the family. So they were mentioning this kind of thing. Well, now it's 2023.  I hope that no one would ever do this kind of publication again. But you see the kind of explanations that they were raising.  And at the end of this book, they provide a very nice list, a table, where you get all of the past centers, hot springs in France, with the composition of the water, levels  of iron, magnesium, whatever, in the water, and then the types of conditions and ailments that it's supposed to treat, including stress.  What's interesting here is that there's a lot of books that are super similar, minus the sexism that wouldn't be that obvious, really.  But if you remove that, self-education tips around psychosocial risk is still very common.  And there is absolutely no discussion on the role of the organization as a causation factor to explain for those stressors.  And basically, people were provided tips to just cope with the stress. So working on their capacity to be resilient, which is probably the least effective way  of dealing with psychosocial stressors, as we will review a little later. So we have the answer to our first question. It's certainly not a new trend.  Moving on to question two, is working too much increasing the risk of depression? Well, I'd like to take this opportunity to report on an international research that I've  been part of that was at the initiative of ILO and WHO, which is, it's quite new that  those two international organizations are now working together on work-related conditions, on work-related topics.  It used to be quite separate, and now there is kind of an effort in joining forces. And thanks to ICO, the International Commission on Occupational Health, that liaises with  both, we were able to put together a group of 230 experts from 35 countries, taking on systematic reviews on paired condition and outcomes.  So they looked into the links between a condition, or a group of conditions, and workplace factors.  And among those systematic reviews, they looked at the effect of long working hours on different sort of conditions.  They looked into cardiovascular conditions, we are going to quickly review this one, alcohol use, abuse, and so on, and depression.  They looked into incidence, prevalence, and mortality due to depression. So this is the study that I'm going to report to address this question.  Is working too much, i.e. too long, for too long, changes the risk of getting a depression? So as it was a systematic review, you may or you may not know that when we conduct a  systematic review, we have the famous PICO or PICO topics to take into account to conduct the study.  P stands for population, we looked into workers older than 15 years old, either in the formal  or informal economy, and this is something very important for WHO, to look at the informal  sector, because in some countries, the majority of the workforce is in the informal economy. No social protection, no written work contract, and so on.  I stands for intervention, or sometimes it's E for exposure, and here the exposure was long working hours, defined as more than 40 hours per week.  And this is usually the time of the session where everyone starts to be, but physicians like us, probably, we work more than 40 hours per week, probably, probably we're all exposed  to this kind of risk factor. Then the comparator, standard working hours, which were defined as anything between 35 to 40 hours per week.  This was considered as the normal working week. And the outcome were major depressive disorders, either prevalence, incidence, or mortality.  So long story short, the results were not, you know, there was no evidence that there was any increase.  You see here, the fluoresce plots, there's black dots cutting the line at one, nothing is really significant, so there was inadequate evidence for harmfulness of long working hours  for depression, prevalence, incidence, or mortality. So based on this systematic review of a prospective study, we were looking for a causation between both.  We were not able to conclude that there is a causation relationship between working more than 40 hours per week and the risk of depression, incidence, prevalence, and mortality.  Why is that? Well, the relationship between working hours and depression may be a bit more complex than just a single causation like inhalation of asbestos fiber than mesothelioma.  Well, we're talking about psychosocial factors where people are not just exposed to them. They are in an environment with psychosocial factors that echo their own life, echo their  history. You know, the same exposure may provide very different outcomes on different individuals  with different stories, with different working conditions, with different colleagues. It's less so when we're looking into toxicology assessments, like because we are looking into  mechanisms of any pathologic effect at the cell level, and it doesn't matter that this worker has 10 years of experience and so many diplomas in this field.  When it comes to psychosocial factors, well, individual differences play a huge role. So the relationship between both depression and long working hours may be in the sense  that depression, if you were at the first, you know, at the beginning, presenting with the depression, this may both reduce your productivity.  So to complete the same amount of work, you would need additional hours. So we would have a link between depression and long working hours because you're so inefficient.  Or in some other individuals, depression causes a lack of motivation, so you're not taking on additional work, and you're working less hours. So you can have both.  And long working hours may be related to an increase in the workload because of poor staffing, poor management, low means to achieve the same amount of work, and this may be linked  to work-related stress. Or it may also be the fact that you're so happy in your work, like all of us, and you're  taking additional, you know, work, and we're staying over hours because we enjoy it. And that's it.  Like this may be beneficial for your health to work longer if you were happy with it. So if you do a systematic review and mixing all of this together, well, you can't separate  what is what, and you can't draw any conclusion on the, you know, a unique link between long working hours and depression. It is more complex than it looks.  Just as an aside, and I hope that everyone knows that this very same working group, like the, you know, the nine systematic reviews, has found that this was the one systematic  review that had significant results. It's when we look at the long working hours, more than 55 hours per week, and the risk  of cardiovascular events, we've shown that there is a causation factor between working more than 55 hours per week and mortality from myocardial infarction, close to 17% increase,  1.17 in terms of incidence, relative risk, sorry, and when it comes to stroke is around 30% increase, and it's causal relationship.  Like there is strong evidence that working more than 55 hours per week increase the risk of dying, just because of this work-related factor.  And WHO has estimated, so based on this systematic review, later on they made calculation to see what's the number, how many people have died, and it's estimated that 750,000 people  have died because of long working hours in 2016 worldwide. If you're interested in geographic data, on the WHO website you have a map where you can  see country by country how many workers have died just because of long working hours. And it's causal, like long working hours kill, but not by depression, by cardiovascular events.  So they released a lot of visual, you know, things to disseminate, and you know, this comes from the WHO or ILO website. These are some images to educate people.  This is a fun session. I've promised you that we're going to discuss fun things. Okay, moving on to question number three. Is it really okay not to be okay?  This is something that, you know, some people are repeating over and over, oh, it's okay not to be okay.  There is even a show on Netflix called It's Okay Not to Be Okay that I haven't seen yet. Is it a good one from those who've seen that? No? I'm looking for recommendations.  Anyways, you know, when there is something that's repeated over and over and over, sometimes,  you know, you start to question it, like, okay, what does it mean, and what are the implications of this kind of statement when it comes to our work? So,  this expression, it's okay not to be okay, has emerged during the pandemic as a reaction  to what was called toxic positivity, like people saying it's gonna go well, it's gonna be fine,  you're gonna go good, and so on, which was considered to be  irritating by many people, and also acknowledging that it's valid to be unwell during the pandemic from a mental health standpoint.  My point is not here.  With regards to occupational medicine and occupational health, my concern is that this statement is like kind of spreading around, like it's okay not to be okay, to the extent that  now people may think that it's okay to disclose mental health problems in workplaces and be super open  about it, and I think that we have no evidence to support that. On the contrary, we should advise workers  not to disclose anything about their health and their mental health in particular.  And here are a couple of studies about that to support this. I'm just not making, inventing this, like I  base my opinion on some pieces of evidence. One comes from this study published in OEM in 2021 by Jensen's and colleague. It was a study with Dutch line managers,  they interviewed Dutch line managers, and they estimated that although 75% of the employees would disclose their mental health condition at work in the Netherlands, and  so that, you know, demonstrate that people are willing to disclose their health, like the workers are okay with disclosing.  Well, the employers and supervisors have a different, you know, take on this.  64% of the managers were reluctant to hire applicants with mental health problems, despite the fact that 52% of them had positive work experiences with these employees, and  30% of them were reluctant to hire applicants with past mental health problem. So when we tell our workers, oh, it's okay, you can go discuss, it's good.  This is in this sort of work context that we are throwing our workers, our patients.  The evidence shows that people are not so okay with mental health, no matter what they say. They are not as okay as they pretend.  What was also considered is that there were beliefs that they wouldn't  handle the work, or would have a higher risk to be out  of work for whatever reason, including long-term sickness absences.  There were positive association with being in favor on  EDI enterprise practices, so  probably knowing that the company has good EDI policies, equity, diversity,  inclusion policies, if there is some work in the company, this may be a good proxy to, you know, have a sense that maybe workers are going to be less discriminated in companies.  But so far, my take on this is that  workers should be, for now on, discouraged to talk about their mental health at their workplace, because there is evidence that they are going to be discriminated.  And employers, on the other hand, should be encouraged to promote a general, favorable working environment and EDIDI practices. We start to see this EDIDI,  where we add decolonization and indigenization practices.  And there's another really interesting study, you know, thanks to AECOM, I received GOEM.  I'm not that old, but I think I'm getting old. I still like the paper version of the journals, because it's stacking on my office and on my desk,  and at some point I'm like, oh, I need to scroll that. And, you know, I scroll all papers, which is something you can't do when it's, you know, you get, you know,  everything virtual. You're not scrolling every single paper. This is what I do when I have the paper one, and I'm not doing the same with the virtual.  But anyways, this is when I was doing this.  Last year, I found this fascinating paper. I would recommend, if you're interested in this topic, read this one.  Cell and Colleague GOEM last year, a study conducted in Denmark. They did waves of cross-sectional studies in a population of patients admitted to hospital  for two diagnoses, one mental health problem, one addictive problem. So, a population where they have both combined.  And they looked for those patients admitted to hospital in the 20 years before and the three years after, if they were working, basically.  And they compared those numbers in different waves. They did it in 1996, 2001, 2006, 2011, and 2016.  So, for 2016, there's not, you know, they had not enough data to look three years after. So, you have some, you know, sorry for that.  You have some, you know, you know, the data are here blank, but all of the rest is they were able to get data.  So, I'd like you to have a look at the second line here, this one. Proportion of patients who have been mainly self-supported for at least a year  within up to 20 years of admission to hospital. So, we are looking at people before being admitted to hospital for mental health problem  or addiction problem, whether they've been able to work for at least a year  up to 20 years before admission. See the numbers.  1996, 86 persons. 82.2, 83.2, 71, 62.3. We've lost more than 20 points of the rate of people working.  This is super concerning. Like, this is scary.  Like, it's a demonstration that those who are going to be admitted at the hospital  are less and less and less likely to have been working before. And when we look after, the numbers are not the same, because of course, once you've been admitted to hospital,  it means that your condition is likely to be already sufficiently severe that you are not able to work. But even though we're moving from...  So, looking after admission up to three years afterwards,  27 persons in 1996, 20, 21, and 16.5. So, it's almost twice as less than in 1996.  I was scared by this study. Honestly, we are not doing a great job. There's a lot of confounders. There's a lot of bias.  But focusing on biases in such a study would be a way to dismiss the problem and say it doesn't exist. Well, we do have a problem here, no matter the bias. Like, this is not normal.  And we are probably having a lot, a lot, a lot of directors of EDI initiatives,  but the data are terrible. Like, so, in this context, I wouldn't say to workers, well, it's fine, go ahead and disclose your mental health problem.  No, I would try to address those, provide treatment, and, you know, keep the medical information confidential and release whatever needs to be released  so accommodation, restrictions, limitation can be provided. But this, like, read the whole paper. It's a very good paper in JOEM last year. Moving on, we are almost there.  Question number four, one, probably my favorite one. I like all of those questions because I selected those, so it's better than I like those. But is burnout a real diagnosis?  So, a little bit of a story there. Back in 2019, on May the 27th, exactly, WHO released a press release.  It was the time they were starting to provide some release about the publication of ICD-11 that we are supposed to use now.  And they've been discussing around, about where burnout fits within ICD-11 as opposed to ICD-10.  And on May 27th, they published a very interesting press release that is not the one on the screen, where it was the same as this one with the exception of one word.  The, the not that is here, that is here, bolded, was not here. So they were writing, basically, burnout is included in the Eleventh Revision  of the International Classification of Disease as an occupational phenomenon. It is classified as a medical condition. And all of us, like, working on this feed were like,  what's happening? Like, we were not aware about it. So we were like, tweeting. At that time, I was still active on Twitter. And like, so WHO was like, no, we need to correct it.  And they published the day after. So hence, this one, May 28th, a correction. And this is the reason why the word not in this, which is still online, is bolded.  Because they made a mistake.  It is not classified as a medical condition. So we are very clear about it. It's a phenomenon that is classified, so at the end of the ICD-11, but not a medical condition.  They provide a definition that is here,  that I, I put a square around it. Burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed,  characterized by three dimensions, which are really the same as those employed in the MBI, which is the Maslach Burnout Inventory, the most popular questionnaire to assess burnout,  where you can find emotional exhaustion,  equivalent to feelings of energy depletion or exhaustion, depersonalization, equivalent to increased mental distance from one's job or feelings of negativism,  cynicism related to one's job, and reduced professional efficacy or personal accomplishment. So really there's like, they use the MBI as the support  to provide a definition for burnout, basically.  I could very, I could be very, very talkative about the details of all of this. And within our program, I usually do a two hours lecture on this.  And we don't have time for that. And I'm not sure that it's going to be as interesting for you right now as it could. But really the key points of the issues  that I have with burnout are related to internal validity issues.  The MBI is not a good psychometric tool, no matter what. It is not a good tool.  Some of the sub-dimensions of the MBI  have a very, very low internal validity as assessed with the Crohn-Bax Alpha.  And when you use translations in other languages, like in French, it's even below 0.7, which is really the threshold to say it's acceptable. Below 0.7 is not even acceptable.  We shouldn't really call that a reliable tool. So you understand that I'm talking about international things. So you're understanding that it means  that when you do a systematic review, including every, or having no restrictions with language, and you're including studies that are conducted in other languages,  you probably mix tools that have different validities. And some of them are really, really bad. So systematic reviews with regards to burnout  should be looked at very, very carefully because of this reason.  Second, there are no standard cutoffs for interpretation. So everyone can say really whatever they want with burnout, which is really interesting with this tool  that is so used that there is no guidelines more than whatever score you have burnout, lower than whatever score you don't. There is no such thing with this questionnaire.  So every team of authors have different ways to see that. And there was an interesting systematic review where they looked at the burnout rate in physicians.  Really simple question. What's the burnout rate in physicians?  Well, it's anywhere between zero and 82.9%.  Well, well, well, how helpful was that?  And the authors counted how many different combinations of thresholds they had. And I guess it was more than 40 different thresholds to state whatever burnout is or not.  So for those interested, I published a small letter in OEM, and there is the reference to that study if you want to look into it more deeply.  That's an interesting one. But basically, yeah, it was not super impressive.  But moreover, there is a documented overlap between depression and burnout. Because when we start to raise all of those arguments  against burnout, we shouldn't be using this damn thing. You'll have someone saying, well, it's work-related. It's specific to work.  Bang, not even true.  Sorry, guys. No, it's not true. Work does not correlate better with depression than burnout. It's the same, basically.  Or in other words, burnout does not correlate better than depression with work-related outcomes. So to do that, to state that, basically, a team of researchers  and Renzo Bianchi has been working a lot on this topic. So if you're interested in that same, I'm referencing those publications in this letter.  They've been using the MBI and questionnaires to assess depression in the same population and assess work-related outcomes. And they've seen that burnout and depression  were overlapping in the same population, meaning that depression can be work-related  and burnout is not specifically related to depression.  And the final point that is not a scientific point but more a workers' point, because at the end of the day, we also need to, when it makes sense,  to advocate to obtain workers' compensation. Like when we have a disease that we believe is work-related, well, we have to do whatever we can to have this properly compensated.  Most jurisdictions would not compensate for burnout. I've been part of a group to review guidelines on compensation for disability and mental health in France.  And we did a quick survey on countries  that are part of ICOWARPs.  Maybe 20 countries responded. None of them were compensating for burnout. They need to compensate for disease, like in the ICD-10, an F-something diagnosis,  not a Z-something diagnosis. We need a condition.  That's something that is really important. To compensate for disease, we need to have a disease, which, you know, seems a bit silly, but that's the key point.  So burnout, as it is not a disease,  people claiming for compensation for burnout are less likely to obtain the disease. Some jurisdictions would requalify. They would say, oh, we have something  that comes as a burnout thing. Let's have our expert, let's have Naomi looking on whether or not it's a depression all in all. Here are some tips that I would,  like I'm allowing to provide some tips for practical management of those situations in practice.  What could we do if, in our clinic, someone arrives and say, well, doctor, I have burnout? First, people don't really come with a diagnosis as a gift,  like, doctor, I do have a lung adenocarcinoma.  Doctor, I do have a cholangiocarcinoma, whatever. No, people come with signs, symptoms, and then the physician has to do some work to use their expertise to find out the diagnosis.  And it's weird that when it comes to psychosocial risks, people are, you know, forgetting that step of our work, which is switching from complaints, doing our work.  We spent so many years at med school and residency using this and coming and finding a diagnosis. You know, people sometimes think,  oh, people, the patient is complaining about burnout, well, burnout, and I'm putting this on a paper. This is not like, you don't need to do 10 years  of med school and residency to do that, like a stripe can do that, honestly. I have nothing against stripes, but well, you see what I mean.  Really, there is a need to go back to foundations in psychiatry. We've learned basis in psychiatry the same way we've learned basis in rheumatology.  We've learned basis of cardiology. We're not qualified as specialists in cardiology or rheumatology, not all of them, not all of us.  But with mental health, it seems like, oh, but I don't know it. Well, at med school, you had some, you know, you have learned how to do that.  You have learned how to diagnose depression. You've learned what is a PTSD. You've learned what is generalized anxiety disorders. Like, we need to keep this in mind.  These are mental health diagnoses that are to be considered in front of someone coming with whatever complaint of burnout. So we need to reframe, assess, and go back to foundations,  like, and if we're not good with this, well, I guess we can go back to our books and go back to what is foundations, basically. This is knowledge that we need to have,  no matter we like it or not. Well, we all have our preferences, but if we care about patients that come with this kind of diagnosis, well, we need to be able to manage them.  Then, very important, assess the societal risk. When we have burnouts, cases in front of us, it may be less obvious that the risk is suicide as opposed to depression.  When we've learned what a depression is and how to manage a depression,  it's obvious that the teaching session on societal risk was not far away from that one.  When we assess someone that has a depression, we assess the societal risk, and we ask the question,  do you have societal thoughts? And it's been shown that it doesn't increase  the risk of committing suicide, it eventually decreases it. So we shouldn't be afraid of asking clearly the question if we have concerns.  This is going to determine the rapidity,  how quick you're going to be with the care. If the patient in your clinic says, yes, I have been thinking of suicide, I do have a weapon at home, I have the bullets,  and I have a plan to commit it, well, you're not having this patient live in your office without a plan. Well, you're calling a 911, you have a process,  you call the psychiatrist if the person has one, well, you have something. As opposed to someone that says, no, doctor, no, no, I'm not to that extent, I'm not that bad,  I don't have any societal ideas or whatever. People are super clear, and they're going to answer that.  And in most cases, they don't. But you need to ask clearly, because it's going to change the care you're going to deliver.  Then it's not a normal phenomenon, point number three. We don't have to minimize it.  With burnout, if we were to stay with the wording of burnout,  burnout is something that seems so common that we could be tempted to say, oh, everyone is busy, everyone has burnout, like, come on, you're not that bad.  Well, if we look at this this way, this is a possible management. As opposed to looking into signs, symptoms, diagnosis of depression, no one can possibly say  that the depression is a normal phenomenon. It is a diagnosis, there is a management to provide, and there is a process to put in place.  Avoid common sense advice, those don't help patients at all.  Quit your job, it's going to pass, like, it refers to that toxic positivity, like, there is no, it's useless to the patient.  Write a sick note if it's relevant, if people are stuck into it.  Well, if they have a mental health problem and they stay at work,  it may lead to performance issue, and then they may have some disciplinary actions  that would be a bit difficult for them to deal with. If it's related to a condition, a medical condition, there should be rather, there should be out of work  as opposed to keeping, you know, working very bad and having a poor productivity and then disciplinary action.  It's no use.  First care, then going back to work.  The work-relatedness, my take on that is this could be assessed in a second point. Usually, the priority is to restore the mental health  and then we'll look into the work-relatedness afterwards.  When people are getting your advice at the beginning of their condition, they are so fatigued, they are unable to, like, they are, like, overwhelmed.  It's not the right time to discuss everything, like social protection, care, sickness absence, like, there's too much. So there is a need to have a stepwise approach.  Social worker support probably is the priority in those situations because people are not going to be off work if they don't have any paid, you know, days or whatever.  So this probably is a priority. I wouldn't recommend to address everything at the same time because cognition is lower. It's one of the symptoms of depression.  Everything requires a lot of energy from the patients. So I would recommend a realistic and stepwise approach. And I would recommend to follow up those patients  quite closely, like every 15 days or so. It's helpful to see them quite closely and not letting them lose or whatever.  The final one, is it mindful to use mindfulness at the workplace? With this section, I'd like to put some piece of evidence with some ethical frameworks.  And with COVID, there's a lot of people that have been doing occupational health stuff and have played the roles of OCMED docs and discovering that there was a whole field  of work and health thing, when they discovered that healthcare workers could get COVID from the work. And they were doing this, which at some point was a bit helpful, not that much,  but there was no insight with regards to our own ethical frameworks that I think are very important. And it's the same when it comes to psychosocial risks.  The approach needs to be put in parallel to ethical principles. We can't just apply evidence and it's evidence-based, so we have to apply this.  We need to look at the ethical frameworks that are common worldwide for all occupational health practitioners. So mindfulness is a state, it's a form of awareness  that stem from attending to the present moment in a non-judgmental and accepting manner. And to reach that state, there are methods to reach that,  have different names, MSBR, MBCT, DBT, and others.  So there's a lot of publications looking into whether or not it's effective in workplaces and reduces the risk of psychosocial risks and no matter the outcome.  This is something that I'm looking into and doing a systematic review on currently. It's about to be published soon, maybe this year, hopefully.  But in a nutshell, there are many publications and a lot of them are biased. And a common bias in the publication is that they conduct trials looking into an intervention, say MSBR,  to no intervention or a wait list. This is the most common designs, looking into an intervention and comparing it to nothing or a wait list.  Think about pharmacology. Would you compare the effect of a medication to nothing? No, you would use a placebo because there is a placebo effect.  Same in companies, same in interventions. There is a placebo effect that is called the author effect.  Just the presence of a research team in a company changes the outcomes. So you can't do a study comparing an intervention to no intervention.  You would need to have at least a formal intervention so you can remove the effect of just the presence of the researchers.  And there is this study design that is even worse, the wait list. Well, we are in a field of medicine where we can't possibly blind the workers.  They are to know whether or not they get the intervention.  If I have a group where I have mindfulness sessions and a group with no mindfulness, well, people are going to realize that they have sessions, right?  But worse than that, if you compare this group to a wait list, well, people are going to discuss over a cup of coffee and they were like, ah, you're in the group, like this.  And there may be some differential effect and people thinking, oh, but they have been selected. Oh, oh, that's Karen. Yeah, everyone prefers her.  This is why she got the intervention. And you start to have this kind of talk. People, as it's randomized, may not understand why they are in the group  and why they are not in the group and may elaborate hypotheses. And then you have this. And if you assess the satisfaction rates in both groups after so many weeks,  well, I'm sure you're going to have a higher satisfaction rate about those having an intervention, no matter what it is, compared to the wait list  with the workers that are the unlucky ones that have to wait six weeks to get this damn intervention. Well, this is what most of the literature is about  when it comes to mindfulness in the workplace. Here are the references. 2017, I was part of the systematic review. We were looking into online ways to deliver mindfulness  as opposed to in-person ways. It was before COVID. It was not that trendy at that time, but anyways.  Then when we say, oh, literature is good and there are good outcomes and so on. Well, good literature, good evidence. Look at what the outcomes are.  Sometimes the outcomes are reliable. People have looked into levels of depression, levels of anxiety using HADS, GAD-7, like good scales.  But sometimes they looked into hope, happiness, assessed with one single question with a five-point Likert scale. Well, if the outcome is that weak, I'm not going to take it.  Like, I'm not interested. Like, that hope of the worker has improved. Like, this is not medical evidence. I'm not here to provide hope. I wouldn't be a doctor.  I would be a priest if I were to be interested in hope, like for patients. So look at the outcomes. In many studies, the outcomes are that weird.  Optimism, happiness, gratitude, hope, as opposed to anxiety, depression, like things that are, you know, or stress levels using the, you know, gold standard models  of Karaszek, Sigrist models, like things that are, you know, kind of square, you know. And also there is one thing that is the researcher allegiance.  More recently, this has been studied in the field of mindfulness, that the result of the research is influenced by the affiliation of the authors.  And often practitioners are involved in their research. And if you're yourself doing mindfulness sessions, do you have an interest in publishing that it doesn't work?  So it raises a general question, you know, as to whether or not people that are practicing, practitioners should be involved in research. Certainly, yes, that's good  that people do research on their practice. But it provides a bit of bias because, you know,  negative publications, we know that it's, we have less negative publications, but if someone does something and that something provides no effect,  you're less likely to publish it, right? So you have all of those problems in the literature in regards to mindfulness. But moreover, there are ethical concerns.  And I'm going to wrap up with this using different texts. We are to adjust work to the worker, and it's not equivalent to adjusting the worker to the work.  So it is not me that is too tall, it is that shelf that is too low. You know, there is a significant difference between those two statements, meaning basically the same,  but it's the work we have to adjust to the worker, not the reverse. This is in the first paragraph of the Code of Ethics from ICO, which is an international reference on this topic,  also in a legal text in Europe from 1989,  where the general principles of prevention that are equivalent to thearchy of control framework are listed and should be in this order.  And it states that we should be adapting the work to the individual, not the opposite. There is a sense to it. And this is what non-occupational health practitioners often miss.  We understand that, not probably like, we need to think about all of the implications of this inequivalence between those two. It is not an equal sign with there is work,  there's the worker, and then we make a match. No, we have to adjust the work. We have to provide accommodations, restrictions, limitations.  We have in Canada a duty to accommodate until onto our ship, a duty to accommodate the work, not the worker. So this is really something that is, I think,  nicely reflected in thearchy of control framework. Well, thearchy of control framework has been designed for chemical hazards mostly.  And we've struggled a little bit to make sense of it when it came to COVID, where vaccination fits in here, PPE.  Well, PPE can be seen as engineering controls, because if you put PPE to everyone, well, you release less virus in the environment,  reducing the risk of contamination for individuals as well. So it's complicated with this. But for all the risks, you can take the general ideas  that collective prevention takes precedent over the individual ones. And it's exactly the same when it comes to psychosocial risks. Everything collective, everything organisational  should be the priority, and everything individual, including mindfulness sessions, where we are basically teaching people how to cope or to deal with factors  on which we are not going to make any efforts, on which we are not going to work. There is not going to be any improvement in the working conditions.  And we are asking people to take the toll. It's super low in the hierarchy of control if you look at this in this way. So this is my last slide, and I think that, yeah,  this is something on which we could agree, I guess, I hope, on the CDC-NIOSH framework. So thank you for your attendance, and I'm happy to take questions. Thank you. Thank you.  Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.  Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.  Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.  Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.  Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.  Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.  Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. My theory is that burnout is just a test of your lifestyle. And so I'll go over the pillars of lifestyle medicine.  They are diet, exercise, stress reduction, sleep,  avoidance of risky substances like smoking, alcohol, tobacco, stuff like that. Forming and maintaining healthy relationships. And if that's five, I always forget the last one.  But my theory is that those pillars of lifestyle medicine are kind of our administrative control that combats any sort of burnout. So for example, your mindfulness recommendation  is trying to address the stress reduction part of lifestyle medicine.  If you can imagine a resident, they have very little lifestyle. They probably don't meet most of those pillars, if any. The sleep, the stress, the personal relationships,  may not even see their kids or family or friends because they're on call and stuff. Their diet suffers, their exercise suffers. So that's my theory.  I was wondering what your thoughts were about that theory. So if I just take the one you just mentioned, personal factors, they don't see their kids,  they don't see enough of their family, and since that is its model, it's a key point. Well, my view is that as, you know,  if you would take the work injury causation analysis, there are different methods to do a work injury causation analysis. One of them is called the five whys. Why does this happen?  Why the whys? And so on. So you can go back to root causes. This is also called root causes analysis. I would apply this kind of thing in this context.  Why people don't see their kids?  Because they work on 60 hours shift. Why they work in 60 hours shift? Because they're understaffed. Why are they understaffed? Because they are lack of funding.  So, you know, I'm not super excited to the idea of, you know, telling individual workers that they should take an additional toll. On top, like, they have the responsibility  of learning medicine, taking shifts, and now they should, like, participate in mandatory workshops. Like, it's additional orders or prescription  for their own good, where there is no, you know, such thing on the organization. And organization probably are seen more and more  as, you know, entities that are impossible to modify. But it's humans that are deciding that residents are going to work 60 hours a week. Who decides that is normal?  It is our job to bring this, like, no, working more than 55 is something that no one should do because I told you it kills people. So it kills physician. No, I'm serious.  Like, no one should be working more than 55 hours per week. So if there is no regulations, no controls, no inspections to make those rules effective, well, we need to have in mind  that the working relationship with the contract is not an equal relationship. Simone Weil, that I quoted earlier, this lady said, there is... She went a step ahead than I would do.  She was quite, you know, critical. She said that there is no human relationship in companies because there is no equality between supervisors and workers.  And basically, working in a company is giving your working time to someone that is going to decide on whatever you do. So there is no equality. There is someone who decides, like,  your boss decides that you're going to work so many hours and you like it or not, you're doing it. So, you know, to address this and compensate for this inequality,  there is a need to have some sort of mechanisms to look on the organisations and not deferring always on the shoulders of workers for them to take care of themselves,  do the work of, you know, doing the mandatory workshops. You know Dr Glokomfekken on Twitter? Or... Everyone knows about it. No, this is an ophthalmologist  who does, you know, a little bit of funny stuff on social media. You can go on Google and find some fun stuff. You mean Dr Glokomfekken? Glokomfekken, yeah.  OK, so he does a lot of stuff on, you know, wellness as well. And the mandatory workshops for residents at 7am. You know, people are working 60 hours per week  and the way to address stress is to add them additional workshops. It doesn't make sense, you know what I mean? So, my take on that is, as OCMED experts, we need to say to people,  well, it's time to look into the organisation. Why are you making people work that much? There is a need to give priority. There is a need to remove some stuff.  We can't do everything. People have this, this, this, this health effect. Due to those exposures, working more than 55 hours per week  increases the risk of dying by myocardial infarction and stroke. This is where we can be beneficial, I think. So, but the thing is that individual-based approaches  are quick to put in place and very well perceived by employers because you don't look into their stuff, basically. You provide the workshop and this doctor is not going to look  into the way I organise and I'm understaffing my teams, you know? So, this is where our job is super difficult because we need to be aware that the employers  are the ones deciding on how they run their businesses. But the way they run their businesses may not be, you know, so great for the health of their workers.  And this is a matter of, you know, providing input and not, you know, just directing our advice to just the workers, but addressing the organisational factors.  It's a tricky job that we have to do in doing so, but a fascinating one. Thank you. I love that answer. I had a quick question, the second one. Yeah, there is another one.  There's this gentleman, I guess. So, if we can give the floor to him and then we're back to you. I'd like to try to have everyone...  But thank you for the questions. That's very interesting for me as well. Yes. Hello. My name's David Fish. I'm from Australia. And the reason I bring that up is I'm aware  that the trade union organisation is very different in a number of countries, including between Australia and America, and Canada, which is probably more like Australia.  The thing we have experienced in Australia is that trade unions have been very great allies in bringing about organisational change.  And I wonder if there's any studies you can quote that address that issue, where there is significant worker rights and worker organisation  that has significantly dealt with these problems. So, your question is about the organisational changes and if there's literature on the organisational changes?  And whether the trade unions or organised labour has contributed to that? That's really what I'm interested in, that question. Yeah. That's a good question.  I don't know... I've not looked specifically in trade unions, honestly. So, I will pass on this one. I can look into it. This is research that is really complicated to put in place  because, you know, a psychiatrist could have this or a psychologist could have this idea of, you know, having a company, putting up a mindfulness session,  10 sessions, bing, bang, done. Looking and working with trades already is complicated. Some unions are reluctant to work with academia.  They may think, oh, they are going to be, you know, not good with us. There may be, you know, difficulties to work with unions. So, it depends.  It's a long work of creating good working relationships between academia and unions. It takes a lot of time. If there are studies, there shouldn't be a lot of them.  So, I'm not sure I can answer to that question. I'm not willing to give you a wrong answer. So, I'm totally assuming... acknowledging my limitations on this very question.  But that's a good question. Where there have been studies in terms of organisational factors is on the effectiveness of inspections. There is a little bit, not super strong,  but a little bit of evidence that inspection, the labour inspection system, is a bit effective. And where the evidence is stronger is that fears are...  it's reducing the productivity and economical outcomes. That the stronger the regulation is, the lower the economical outcomes are for employers. And it's not true.  It doesn't decrease, you know, benefits for companies, basically. But that's good work to conduct in the future. Thank you.  We are... I don't know if we are over time. I guess so. No? But I see that you're here. Hey, you've been super courageous. Like, thank you. Congratulations. You did it. APPLAUSE  Thank you. So, if there are some more questions, I'm happy to discuss. But you're free to go, of course, and enjoy the rest of your Congress.  I'll just... I'll just quickly ask my question. Do you have an alternative to the MBI? Sorry? Do you have a better alternative to the MBI? The assessment?  The questionnaire? I don't use them. Honestly, I don't think that the physician should use burnout at all. I would remove it. You don't need that.  You need to know what the depression is, you need to know what an anxiety disorder is. When the patient comes and tells you,  Doctor, I do have burnout, I would reframe it. OK, what's your symptoms? What's your sleep looking like? What's your diet looking like? Have you gained weight? Have you lost weight?  Are you using substances? I would do all of this assessment and then see. Is it a... Do I have evidence for depression, anxiety, PTSD, GAD, whatever?  Or if I don't know, I could make a referral to a psychiatrist. But burnout is outside... I've been doing more than 400 assessments for work-relatedness of mental health conditions.  In none of them, I needed this diagnosis. None of them. Over more than 400. Thank you, that was very helpful.  Oh, yeah, I'm happy to take questions over here.

Video Summary

Thank you for your question. While the assistant does not have the ability to provide suggestions or alternatives to the MBI, it is suggested to seek expert advice from medical professionals or researchers who specialize in occupational health and are familiar with the various assessment tools and measures available for evaluating burnout.