When the Past Revisits: Physician Trauma Response and COVID-19

BY WENDY COHEN, MD, PHYSICIAN EVALUATION DIRECTOR, PHYSICIAN HEALTH SERVICES, INC.

Illustration by Chris Twitchell

It can show up as insomnia — disrupted sleep, vivid disturbing dreams, awakening with anxiety. When physicians feel tired, we might drink coffee, exercise, and keep going to work on schedule. It can show up as edginess — being quick to react, short-tempered, feeling on edge. When physicians are reactive, we might brush it off as being stressed. But all can be indications of a response to trauma.

Human beings are products of our past, and our experiences are held in our minds and in our bodies, even when we are not consciously aware. Over the past year, physicians who had experienced traumatic life events prior to the pandemic found themselves living through another trauma. COVID-19 shut down much of the world, but many physicians were expected to carry on with work as usual, first without adequate supplies and then layered with PPE, to forge on in the face of an unknown virus. As a physician health psychiatrist supporting physicians through COVID, I have seen how a prior history of trauma can complicate the experience of providing health care during the pandemic. Now that the punishing pace of COVID-19 care has slowed, the emotional experience of the past 17 months is beginning to surface for physicians. Physicians tend to push through pain and exhaustion to continue their work, but we must remember that our health is integral to the quality of care we can provide. We help our patients when we help ourselves by getting the health care we need and deserve.

“I never expected my career would put me in physical danger,” one ­physician told me. Medicine is a safety-sensitive profession, but we were all caught by surprise when our own safety, in addition to our patients’, was compromised.

Trauma in Physicians during COVID, and the Benefit of Early Treatment

Trauma can come in many forms. It may involve an experience when our own physical safety was put in danger — such as being assaulted or abused. Sometimes it is when we are hurt emotionally. Or it involves seeing or hearing about another person being harmed. It always involves the experience of fear.

When the body experiences this fear reaction, at any point in our lives, it can be stored as a memory. The memory can be multisensory, such that any exposure to a sensation, smell, sight, or experience that is, even in a small way, similar to that of the first trauma, can bring back the body memory. The result can be recurrent memories or dreams about the event, somatic symptoms, avoiding things you associate to the event, insomnia, poor focus, fear about safety, being easily startled by loud noises. It can also lead to a sense that you aren’t real or are split off from your body, watching from above. Or it can make people feel detached and find it hard to feel happy. This type of memory triggering, while common for people who experienced trauma in the past, does not happen to everybody. It is not clear why only some people have this type of response, but research is being done to help us understand.

In a study done in fall 2020, 1,800 health care workers (HCWs) completed a survey screening for symptoms of post-traumatic stress disorder (PTSD) and it was found that 36% of physicians had PTSD symptoms. HCWs with PTSD demonstrated a higher rate of suicidal ideation than those without PTSD (16.8% vs. 3%) and higher rates of feeling isolated (78.4% vs. 41.8%). Symptoms were worse for those who worked longer in COVID-19 units, for younger providers, and for those who contracted COVID-19.

In another study, a Veterans Affairs psychiatrist identified parallels between the veterans she treated for PTSD and HCWs and first responders (FRs) who worked during COVID. She developed the ATTEND study, an ongoing survey of HCWs and FRs. Preliminary, unpublished data suggests working through COVID-19 has led many HCWs and FRs to experience PTSD symptoms. She found a sense of demoralization significantly contributes to risk of developing PTSD. Physicians’ sense of purpose is compromised, as is their health, when they don’t feel good about the care they are providing and the system within which they are working. This research suggests that addressing demoralization and treating the PTSD symptom of hyperarousal early may prevent development of chronic symptoms of PTSD. And it shows that addressing the struggles of HCWs and FRs will keep them healthier over time.

Demoralization, Burnout, and Loneliness Add to Risks

Whether or not physicians had a history of trauma prior to COVID, many struggled with the challenge of providing optimal health care during the pandemic. Demoralization is also a risk factor for burnout, a job-related syndrome characterized by emotional exhaustion, cynicism, a sense of reduced effectiveness, decreased sense of meaning found in work, and feelings of depersonalization. More than 40% of US physicians are facing burnout, and many in my field anticipate that COVID-19 will increase this rate. There is an association between burnout, depression, and drinking. Physicians with burnout are at 25% increased risk of having an alcohol use disorder and twice the risk of having suicidal ideation. Alcohol sales have increased during the pandemic and use by physicians has also been on the rise. A Medscape survey of physicians found that during COVID-19, 64% of US physicians report more intense burnout, 19% report drinking more alcohol, and 46% report feeling lonelier.

Loneliness is known to be associated with suicide, and physician suicide has long been a hidden crisis brought to light during the pandemic. When New York City emergency physician Lorna Breen, MD, died by suicide in April 2020, the tragedy reverberated through the country in a New York Times article headlined “‘I Couldn’t Do Anything’: The Virus and an E.R. Doctor’s Suicide.” Dr. Breen had worked through the early weeks of COVID with limited PPE, contracted COVID in March 2020, and then returned to the overrun ER with morgue trucks parked in the back. While there can never be certainty about the reasons for her suicide, the issue grabbed national headlines. Solutions to the problem of physician suicide still need to be found.

One physician dies by suicide in the United States every day — a rate (28–40 per 100,000) that is more than double that seen in the general population. In July 2020, The Dr. Lorna Breen Health Care Provider Protection Act was introduced in the Senate to establish grants to address the mental health and burnout of HCWs. The bill proposes training on suicide prevention, well-being, and burnout prevention, and it calls on the CDC to develop a campaign to encourage HCWs to seek support and treatment for mental health problems. It has not yet become law. Reducing stigma around physician mental health care is critical if we are going to improve the health of our doctors.

The Value of Naming

COVID has been a shared trauma, experienced by everyone in the world and threatening the safety of us all. But for physicians who experienced trauma prior to COVID, especially those who were expected to continue face-to-face clinical care, a response to the pandemic may have been amplified by past experiences. By understanding that this phenomenon could be related to symptoms of PTSD, and naming it as such, we give ourselves, as physicians, a chance to receive proper medical care. We give ourselves a chance to understand what our friends and colleagues may be experiencing.

A wealth of effective evidence-based treatment exists for PTSD. As a physician community, we share a responsibility to understand what PTSD looks like and support ourselves, our colleagues, and our friends to access treatment. As with any medical problem, without the right diagnosis we are not likely to identify the right treatment.