The editors of Healthcare Quarterly (HQ) recently had the opportunity to speak with Heather Patterson – emergency physician, photographer and author of the recently released book Shadows and Light (Patterson 2022). Through the photographs she took at Calgary-area hospitals during the height of the COVID-19 pandemic, Patterson created a poignant record of how the pandemic affected hospital staff, patients and their families. The book has struck a chord with many Canadians as it offers both an honest appraisal of the dreadful toll of the pandemic while also demonstrating the grace and compassion of healthcare workers.

HQ: Who was the intended audience for Shadows and Light? Was it meant as a way to document what was happening – a kind of “record the moment for posterity”?

Heather: Publishing a book was a surprise! I initially thought I would share my photography work with a series of Grand Rounds presentations to medical staff in Calgary. But over time, the project gained momentum and I realized it may have a broader impact than what I had anticipated. As I wrote the book, I walked through my journey of exploring and understanding our amazing hospital teams. It became a multifaceted story – an inclusive story – about life in the hospital during the pandemic. So to answer the question about the intended audience, I have to explain a bit about my photography project and how it evolved.

It started with my husband's suggestion to take photographs in the hospital even before the pandemic had arrived. I was feeling burnt out and was looking for a different way to reconnect with why I chose medicine as a career. I hoped that I could address some of my struggles with depersonalization, exhaustion and cynicism by creating a virtual story that reminded me, and maybe others who were experiencing the same thing, why we went into medicine or healthcare. So, while it is a documentary photography project, which by nature is a record of this time in our collective history, my primary objective was to process the complex emotions associated with working in healthcare and to reframe and reconnect. So the first intended audience for Shadows and Light is those of us who have dedicated our lives to caring for others – healthcare workers.

As I photographed, I allowed myself the time and space to be curious, to think deeply about how the pandemic was affecting all of us. With this freedom of time and experience, the project unfolded in front of me. I started photographing my own medical world in the emergency departments and then quickly expanded to include other clinical areas: ICUs [intensive care units], wards, clinics and operating rooms. This helped me understand the broader impact of COVID and the scope of work being done to care for patients. It also opened my eyes to the vast number of people who work behind the scenes; the people who aren't at the bedside but are absolutely critical for how hospitals work. As our non-clinical staff shared stories of excellence, dedication and sacrifice, I realized my desire to acknowledge our complete team. With this realization, non-clinical staff became the second part of my intended audience.

This book is also for patients and families. In the early months of photographing, people welcomed me alongside their hospital journey, where I learned about their experiences in more depth and developed greater understanding. I have felt incredibly honoured to be entrusted with their stories. Their vulnerability and willingness to share during some of life's most difficult moments are an incredible gift to us as healthcare providers and as a society. I hope that their stories can help us better understand what patients and families were going through and create empathy in our communities. I don't think we can fully understand the depth of the suffering of patients and family members.

That's a long-winded way of sharing about the large audience for Shadows and Light! But, since the project unfolded in unanticipated ways, and I had an opportunity to later write a book about our experiences, it became a multi-audience story. It is for healthcare workers, non-clinical staff and the people who love us, to understand what we experienced. It is for the people who were in hospitals who were separated from their families and loved ones. And I hope it will generate empathy and compassion within our communities.

HQ: Near the beginning of the book, you talk about how people working on the front line learn to box up their emotions and just say they're fine. You indicated that at a personal level, you found that taking on this photography project allowed you to connect better with your own emotions. Do you think the book may help other people who work in these settings come to grips with their emotional side as well?

Heather: As healthcare providers, we need to have a protective barrier, some emotional distancing. We can't do what we do on a daily basis and help people who are suffering if we're experiencing their tragedy in the moment. But we don't often have the time, the space or the energy to later debrief our own emotions. And sometimes it is easier to box up those experiences rather than work through them.

The feedback I've been receiving from many physicians, nurses, RTs [respiratory therapists] and our non-clinical staff is that seeing the images provides them with the opportunity and space to reflect and feel in an environment where they're not making decisions. They can read the book in their own home, at their own pace, in their own time and look at the images and stories.

While speaking at conferences, I sometimes feel badly because I look around and the room is filled with healthcare providers with tears in their eyes. It is common for people to comment that the images and stories remind them of their own patients, colleagues or even themselves.

I think it speaks to the need for us to have a mechanism of processing – a mechanism for being healthy but still providing compassionate care. It is different for everyone, but I hope that the book could start that process of helping people to process what they've been through.

HQ: For you, the process of recording and observing your colleagues on the front line was a way to reconnect in a different way with your own patients. It sounds like that was successful. Can you tell us what has changed for you?

Heather: Burnout is different for everyone, and for me, it was a combination of being exhausted, feeling a bit cynical and then feeling nothing. I'm a person who has big emotions, and so, this was an uncomfortable place to be.

When I was photographing without the weight of clinical responsibility, I could intentionally look at a person and think, “Wow, this is really tragic. How must they feel? How does that make me feel?” And then this helped me ask, “How can I capture, respectfully, something that shares that patient's story or shares a healthcare provider's perspective?” It helped me see the emotion. I could also look back at the photograph and feel the emotion.

How does that translate into my practice now? I'm more aware of my patients' experiences. I think it allows me to better support my patients through their ER visits and medical issues. I'm not burnt out anymore. Thankfully, very quickly that pendulum swung right back. I am still an expert at tucking things away when I need to be objective and make difficult decisions, but I know what I need to do after, to debrief those tragic cases. I am more aware of my own emotions and can comfortably acknowledge how I feel, and the impact of caring for people in some of life's most difficult moments. I know that this helps me be the best physician I can be for my patients.

The surprising thing about starting to feel, and being aware of my emotions in the clinical environment, is that I see a lot of positives. I can see those moments of joy and connections more clearly because they're more apparent when I'm more present and aware of my emotions. I can see the incredible work of those around me and appreciate and thank the people who, maybe, don't get thanks very often.

HQ: At one point in the book you made the comment that the photography project itself was premised on a wellness philosophy. Do you think this notion of a wellness philosophy is something we could take further and provide greater depth to the care that's provided in hospitals?

Heather: The hallmark features of burnout are exhaustion, cynicism, depersonalization and a lack of sense of accomplishment. For me, the “wellness philosophy” was the idea (and hope) that by putting people at the centre of the project and by acknowledging their hard work and compassionate care, it may offer a different perspective of the challenges we face and promote a culture of gratitude and appreciation. I hoped it would help me work through my own experience, to reframe and reconnect, but also to allow people to see themselves the way I saw them – their excellence, their kindness, their compassion, their technical prowess and their cognitive skills. I wanted to take that and give them a visual representation of how they are seen by others. I wanted to find ways to celebrate unique strengths and to acknowledge the successes that were perhaps not being seen by many. It was a multifaceted approach. It was targeting the comparative culture and starting with a recognition that everybody demonstrates excellence. My wellness is also deeply rooted in how medical culture functions – connection, community and authenticity – and part of this project was learning how to better live by those values.

The other aspect of wellness that I wanted to address is the hierarchical nature of medicine. I wanted to find ways to show acknowledgement to the complete team – for instance, by showing up at the lab department (they were so excited because nobody ever comes to the lab!) or by following a housekeeping or maintenance team for a day. There are incredible stories of what these people are doing, and yet how often are we acknowledging their successes and their contributions? With the project, I hope to share the gratitude and respect I felt for all those working in the hospital.

Do I think we could create a “wellness philosophy” systematically? Absolutely! I love the idea of creating a positive culture and looking for ways to impact our workplace and community. Whether it is photography or other innovative ways to grow, I know that we can continue to move forward.

I hope that I can continue with my project and have an impact – I have so many ideas for photography that will continue highlighting these exceptional people. Every time I bring my camera into the hospital, I leave feeling inspired. Yes, the healthcare system has a lot of challenges these days, but what lies underneath that? We need to just step back from the politics and the crises and move back to the acknowledgement of those incredible day-to-day things that we're still able to do – whether it's a patient interaction or the support we can give a family. It might be the speed at which we can transition patients in and out of rooms, or the decisions that our leadership has made in order to make our patient care feasible at the children's hospital.

All of these things can be celebrated and moved toward that culture of promoting systemic wellness, authenticity and individual wellness. There are so many things that we can do to show the excellence within our system.

HQ: You said that you didn't start with the intention of creating a book. Rather, you started out wanting to photograph and document to take a step back. Have you been surprised by how this has been received and the acclaim that you've gathered?

Heather: I was not expecting this at all. My husband says, “Oh, I knew it would be great.” He's my biggest supporter. Maybe the reason that it has been successful is because that wasn't my intention. I wasn't out there seeking to be in the media or have my images published or to write a book that would be nationally available. So, was I surprised? Absolutely. I still feel honoured anytime I get an e-mail or a request to speak.

The intention was never to turn the lens toward me. The intention was always to turn the lens toward others. It's taken a little bit of getting used to, to be honest. I love people, so I love interacting and meeting people, but the success was definitely not anticipated.

I'm still a mom, and I have a husband who's an emergency doctor. It feels like we run a small Uber service for our children. And I am chronically disorganized, I forgot my kid's orthodontist appointment this morning, arrived at the ski hill without my daughter's skis this week and regularly lose my wallet and keys. I feel like I'm just a working mom running in too many different directions. So, it feels surprising to me to have this type of success and acknowledgement or when someone thinks that I have got it all together!

HQ: Is there one image that you could pick out in the book that above all, sort of, captures the pandemic as it was experienced either by front-line providers or, maybe, by patients and family members?

Heather: The image that comes to mind speaks to both the patient and the healthcare provider experience. It's a photo of my friend and colleague Dr. Morris on the phone speaking to a family member with the patient's reflection in the mirror, intubated in the ICU. This patient got sick very quickly and was intubated after he said goodbye to his family on FaceTime. Every day, the physicians or the nurses would update his family members over the phone, sometimes delivering difficult news of a deterioration or “slower than expected recovery.”

We did our best to provide comfort, care, compassion and attention to both the family and our patients and I did see many moments of joy and hope. But if I was to encapsulate what the pandemic looked like at the bedside, it was often that moment – the separation of patients and their family members and loved ones and the emotional toll for healthcare providers as we cared for so many unwell.

HQ: You don't seem like someone who sits still for long, and you talked about some of the things you'd like to do, so what's next?

Heather: Just at the end of November, I had a shift where I watched a staff member quit on site. Others were in the staff rooms crying. The doctors were struggling, looks of frustration and defeat on our faces. And, I thought, “How can I help in this situation other than just doing my clinical work?”

So, I brought my camera back in. I have been in the hospital doing some more photography work as a means of acknowledging, of seeing the hard work happening every day. I've been on the wards, PICU [paediatric intensive care unit] and the emergency department at our paediatric hospital here in Calgary. I'm trying to document, to encourage people and remind us why we do what we do.

What else do I want to do? There are incredible stories everywhere within our hospitals. I would love to be able to showcase more of Canadian healthcare as a travelling medical photographer. I think there's excellence at every site. Each hospital has something that to be really proud of – something that's unique. I would love to have the opportunity to document those areas of excellence, to be able to expand the reach and have people across the country receive images that celebrate their success and dedication to their communities.

I would love to photograph physicians and nurses who are retiring. We spend our entire careers and so much of our time and energy in the hospital. Yet, very few people have any documentation to celebrate what they've contributed to their communities, to their colleagues, to their patients. I would love to be a retirement photographer – to follow around retiring staff whose colleagues wish to offer them a sincere thanks for the time, energy and care that they've provided in their communities.

I also have a dream to create an art institute in healthcare, an idea inspired by discussions with Michael Suddes, the Foothills Medical Centre director. There are so many talented people in the hospital system. It would be incredible to create an institute where people could apply for mentorship in any artistic domain. It could be linked with universities or colleges, and the applicants could have a period of time to create, whether it's poetry, painting, a sculpture, music, photography or other forms of artistic expression. Then they could highlight and showcase their work in the hospital as a way to enrich the lives of the staff, as well as the patients and families who are in the hospital.

So that's my big dream. I would love to create something that is available to not just a select group of people but to those all who may be interested in pursuing or refining an artistic pursuit or hobby alongside a career of working in the hospital.

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