Reminiscing on residency: Dr. Jonathan Isaac Ailon on deciding how much of your life you want to be about medicine

With snow piling the streets of many of Canada's cities, many physicians will be all too familiar with the roadblocks—traffic, potholes, and other cyclists braving the icy conditions—that Dr. Jonathan Ailon faces on his commute home from St. Michael’s Hospital.But, perhaps counterintuitively, he seems to enjoy the winter's challenges. “When the weather is worse, the bike ride is nicer. There are obstacles, which make it fun,” he says. Winter, summer, fall and spring: Dr. Ailon makes the 25 km trek to and from work by bike almost daily. “I started doing that during COVID-19, because of the transit shortages, and it’s something that I’ve kept up.” Perhaps his penchant for braving severe conditions is intrinsic to his work. As a doctor of internal medicine and the inaugural director of palliative care at Toronto’s Unity Health Network, Dr. Ailon lives in close proximity to pain. For the doctor, the 30-to-40-minute bike rides to and from work have become a way to bookend his days at a hospital that welcomes the most unhoused people across the GTA, and that has one of the busiest emergency departments in the province. “It gives me time to decompress and to humanize the experience that I had,” he says. When he attended McGill University for medical school in 2009, Dr. Ailon aspired to be an intensivist, with a plan to go into neurosurgery. Most of his electives were in critical care, but throughout his training he grappled with what he calls moral and ethical concerns in the care he was providing patients. “We weren’t really questioning the quality of life that patients would have after care.”While completing his residency he was also dealing with family members with severe illness, which he says made him rethink and prioritize how he showed up for patients. It was in doing the clinical work in residency that Dr. Ailon discovered he enjoyed palliative care, and found a specialty where he thought he could make a significant difference in his patients’ lives and that he says aligned with his intrinsic, personal values. “Many people think it’s sad medicine, but in many instances, palliative care is really treating people as humans,” says Dr. Ailon, who enjoyed the deep intimate contact palliative care doctors develop with families over a short period of time. That passion has led him to wear many hats throughout his career. He created a point-of-care ultrasound curriculum at the University of Toronto for the undergraduates and internal medicine residents, which he developed over five years, before passing the work on to another group of doctors who have expanded the program. Throughout his day, Dr. Ailon works on in-patient and out-patient palliative care, does home visits for certain patients, and practices internal medicine. Currently, he’s also working to build and renovate the palliative care unit at St. Michael’s, a process that he says has been challenging. “You’re working with founders and donors, and all hospitals are in extreme financial strains. Even with donors, there are still big impacts to the hospital budget,” he says. “It’s difficult because you need to justify your work. For hospital executives, everything has to have a dollar sign attached to it.” He admits that in trying to balance all of that, he experienced the subtle pang of what he sensed was oncoming burnout once in his career. “I felt a sense of loss of control of what was happening in my life.” His calendar used to be filled with committee responsibilities, his months used to include 32 weeks of intensive internal medicine per year, and he often ended his days at the hospital past 7:00 p.m. “I realized my wife was doing a lot of solo parenting,” says Dr. Ailon. Since then, Dr. Ailon has made material changes in his work schedule, reducing the weeks that he does internal medicine to four, and making an effort to be home between 5 p.m. to 5:30 p.m. on most nights. Those bike rides, he says, have also helped him regain a sense of control, and shake some of what he’s experienced throughout his day, so that he could be fully present with his wife and three kids aged four to 10. 1. What is the biggest thing that residency taught you about being a doctor? There is a tremendous amount of learning that happens in residency. It’s very accelerated learning. Probably one of the most salient messages that I learned throughout my time in residency in internal medicine is this notion that for many patients, there are things worse than death. It sounds like a strange thing to say, because I think for most laypeople—and I was a layperson before I went into medicine and residency—death is the worst outcome. But then as you go through residency, you see the outcomes that patients experience, and just the hardship and suffering that people go through, while they're alive, but not living, and really, for me, that's what helped me realize the importance of really trying to understand what sets value to patients, what gives them a sense of purpose in measuring their lives, and how we can really help them to achieve that. It helped me learn that sometimes the answer is not aggressive therapy, it’s giving a person a quality of life for the time they have left. That was one of the things that I learned that was really impactful in terms of shaping my life and my career.2. What is something you've learned further down in your career?Early in my career as a doctor, I had a desire to be very helpful and accommodating to demonstrate my work. The challenge is that, you’re often starting your career in medicine around the same time when most people are starting families and trying to start their life, right after 14 years of post secondary education. That's the transition point where most of us sort of set the stage for being very involved in medicine and very uninvolved in family life. I think early career is really the time to set your priorities and to decide how you want your life to be outside of medicine, and really to decide how much you want to limit the impact that medicine has on you and your family. You know, medicine does wonderful things in terms of: you have the potential to help impact lives and the work that we do is important, but it comes with the real risk of leading to burnout, marital conflict and distance from your children. So, what I learned later in my career is the importance of setting boundaries early in your career, and knowing that you have intrinsic work. You don't have to sit on 10 committees to justify your existence. If you're able to say no and set boundaries, people will actually respect you for it, rather than value you less. My wife and I had our first kid during my first year in practice. I took a year of parental leave in my second year to spend time with my child, while my wife did a fellowship, and that was probably the year that I really learned about the importance of setting boundaries. I didn't have a choice. I think the longest that any member of my division had taken for parental leave was six weeks before that. So it was setting my priorities, but also, I think, to a degree, helping the division reevaluate whether six weeks was sensible for most people and sustainable. 3. What is your number one tip for residentsWhile you’re in training to be a doctor, you will always have people telling you when you're good at something, and that feels great, and makes you feel like you should do more of it. It’s important to reflect on who you are and what you want to do: what gives you a sense of joy and satisfaction? And also, what you don't want to do in your work, because you have a long career. You have, hopefully, a long professional and personal life. And if you, if you don't set your priorities and your boundaries, medicine will suck you up. There's very real risks in medicine to be used up by the practice that we do. By contrast, if you reflect on what you really want to do instead of what people tell you you're good at, and you honestly reflect on what you don't have the bandwidth for, you can really hone in on the aspects of medicine that gives you joy. That's an essential ingredient to build that satisfaction in work, but also to be really proficient and good at what you do as a doctor.

Reminiscing on residency: Dr. Jonathan Isaac Ailon on deciding how much of your life you want to be about medicine

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