I was traumatized by practice - Chances are you have been, too!

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 be considered a traumatic experience and risk factor for posttraumatic stress disorder (PTSD)?

The concept of trauma, as it relates to PTSD and early versions of the Diagnostic and Statistical Manual of Mental Disorders (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. It should be noted that trauma in the form of violent attacks perpetrated against caregivers is on the rise, along with a commensurate increase in PTSD.

I became interested in vicarious traumatization toward the end of my first year of residency. I was involved in an incident that led to a patient’s suicide attempt (an account can be found here). Although the patient survived, I struggled to keep my emotions 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?” they 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 7 years after I completed my residency – to work in industry settings.

I have been researching the effects of vicarious trauma on physicians for the past 40 years. The extant literature indicates that PTSD occurs in 10-20% of physicians. The 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 are:

• Treating patients with mutilating injuries from high-speed motor vehicle accidents, falls or burns
• Assessing and treating battered infants
• Watching the amputation of a limb in the operating room
• First exposure to an intensive care unit
• Assisting at an unsuccessful cardiac arrest, especially in a young or previously healthy patient
• Listening to the painful story of someone who has been brutally raped
• Witnessing the labored breathing of someone who is in pulmonary edema and who is fully conscious and terrified
• The death of a patient whom they were attached to
• Being “pimped” and feeling put down, bullied or humiliated by an attending physician

PTSD symptoms in physicians have increased during the coronavirus 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, healthcare 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 because the concept of moral injury was first described in service members who returned from the Vietnam War with symptoms that resembled PTSD. However, Dr. Pamela Wible, an authority on physician wellness and suicide, eschews the comparison. She writes that “wounded healers wound each other,” and that bonding over trauma – for example, support groups – simply creates trauma bonds that lead to maladaptive behaviors such as substance use to numb the effects of trauma.

“Befriend each other,” Dr. Wible tells graduating medical students, “by doing stuff normal people do. Go on a hike and cook dinner together…the best way to prevent trauma bonds is to first bond over your hopes and dreams.” That’s good advice for medical students and interns, but it may not suffice for busy physicians working in the trenches, where ongoing, untreated emotional trauma 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 physicians’ 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, 1 in 5 physicians intends to leave practice within 2 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

Mental health professionals can choose from a variety of patient-centered, evidenced-based interventions to help physicians suffering from the effects of vicarious medical trauma. Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT), Mindfulness-Based Cognitive Therapy (MBCT), Accelerated Resolution Therapy (ART), Eye Movement Desensitization and Reprocessing (EMDR) therapy, neurofeedback, narrative writing therapy, and other holistic models can help physicians redefine and rediscover healthy relationships with their patients and themselves. It is critical to remain holistic in the approach to treating medically traumatized individuals because their traumas are complex and affect the mind, body, and spirit.

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.

Arthur Lazarus, MD, MBA, is a member of the Physician Leadership Journal editorial board and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia.