When it comes to trauma, the focus of attention is our patients, recognizing their adverse childhood experiences and learning how to provide trauma-informed care. But what about us — the healers, the first responders, the listeners, the front-line physicians? Can practicing medicine also be considered a traumatic experience and risk factor for PTSD?
The concept of trauma as it relates to PTSD and early versions of the DSM depicts devastating events such as natural disasters, sexual assault, military combat, and physical attack. Over time, however, the DSM has expanded the list of potential stressors. Now, in its fifth edition (DSM-5-TR), the manual recognizes indirect exposure to trauma, including aversive details of traumatic events, as possible stressors resulting in PTSD.
The DSM also states that professionals may be indirectly affected by trauma in their line of work — for example, psychotherapists exposed to details of their patients’ traumatic events. However, the DSM stops short of identifying physicians as indirect victims of trauma, even though they, like psychotherapists, may be exposed to traumatic events incurred by their patients.
The terms “secondary trauma” and “vicarious trauma” have been used to define a spectrum of symptoms and conditions that have resulted from exposure to traumatic material or the account of patients’ traumatic exposures during treatment. Vicarious trauma should be distinguished from trauma typically seen in PTSD — trauma that involves direct exposure to actual or threatened death, serious injury, or sexual and other bodily violence.
I became interested in vicarious traumatization toward the end of my first year of residency, when I was involved in an incident that led to a patient’s suicide attempt. Although the patient survived, I struggled to keep my emotions about the incident in check. I guess I failed, because many of the faculty noticed I had become anxious and depressed. I tried to “cherry-pick” my patients, avoiding, of course, those with suicidal ideation and other anxiety-provoking conditions. “What’s wrong with Art?” my colleagues wanted to know. I was actually put on probation because my depression was affecting the quality of my work.
I reached out to a senior psychiatrist who helped me in therapy. My depression gradually lifted, and the whole ordeal was apparently forgotten by the time I was in my final year of residency. I was even appointed chief resident. But the scars of the trauma never completely healed. It was one of the reasons I left practice prematurely — just seven years after I completed my residency — to work in less stressful industry settings.
Since then, I have been researching the effects of vicarious trauma on those of us in health care. The extant literature indicates that PTSD occurs in 10-20% of physicians. Main stressors include treating trauma patients; working in conflict zones; working in underserved, remote, or rural areas; and the cumulative effects of on-the-job stress.
The incidence of PTSD in medical students and residents approximates that seen in practicing physicians, but the stressors tend to be different. Clinical situations that trainees might find traumatic include — but are not limited to — treating patients with mutilating injuries from high-speed MVAs, falls, or burns; assessing and treating battered infants; assisting at an unsuccessful cardiac arrest, especially in a young or previously healthy patient; and being “pimped” and feeling put down, bullied, or humiliated by an attending physician.
PTSD symptoms in physicians have increased during the COVID-19 pandemic, and the pandemic, itself, has been declared a traumatic stressor. Although the threshold for full-blown PTSD may not have been met in all instances, health care workers have experienced alarming levels of moral distress and moral injury during the pandemic — wounds from having done something, or failed to stop something, that violates their moral code. There is an evolving understanding that moral injury may set the stage for PTSD, often compounded by shame and guilt. Moral injury at the height of the pandemic stemmed from being unable to provide adequate care to dying patients and counsel individuals on ways to slow the spread of COVID-19.
Physicians with PTSD have been compared to wounded soldiers, insofar as the concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that resembled PTSD. Though the trenches today’s physicians are working in are non-literal, they may nevertheless suffer ongoing emotional trauma that may affect not only themselves, but also their families and patients. If not addressed promptly and appropriately, the emotional impact of trauma may influence a physician's career trajectory, as it did mine.
I have no regret about leaving practice, but other physicians I’ve spoken to have expressed remorse that they could not continue seeing patients due to PTSD. One physician wrote to me and said he was traumatized by a malpractice lawsuit and further traumatized when pressured to settle out of court. Failing to “get his day in court,” where he was certain he would be vindicated, largely contributed to his PTSD and “emotional inability to stay in practice.” In fact, pushed to their limits by various stressors, one in five physicians intends to leave practice within two years.
To counteract the “great resignation,” a three-tiered model to provide escalating support for physicians with PTSD has been recommended:
- The first tier: Emotional support from trained peers (not “wounded” clinicians)
- The second tier: One-on-one support and group debriefings when the whole team experiences an unexpected patient outcome
- The third tier: Referral to a professional mental health counselor specializing in PTSD and other trauma- and stressor-related disorders
As clinicians, we have been tasked to learn and apply the principles of trauma-informed care to our patients to achieve better outcomes. A deeper understanding of the causes of trauma-based disorders and their treatment also opens our eyes to issues we may have overlooked or ignored in ourselves — namely, the toll of medical practice on our psyche and well-being.
How do you care for yourself in traumatizing or upsetting medical situations? Share in the comments below.
Arthur Lazarus, MD, MBA is a former Doximity Fellow. He is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry in the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.
Illustration by April Brust