The (micro) traumas of medicine
Introduction
Trauma.
Outside of the armed forces, few professions are exposed to as much human suffering as in medicine. Which other profession exposes its workers to as much blood, guts, and death (and, occasionally joy)?
The life of a physician is one of the most stressful vocations. Not only do we face a constant barrage of patients and their various health concerns, but we must also balance this with the administrative aspects involved in running our practices. And while many physicians have developed healthy ways to cope with these stresses, others find themselves struggling to keep it together — and some suffer from burnout, depression, anxiety, addiction, or PTSD as a result. In this article, I’ll discuss the trauma of medicine, and what can be done about it.
Big T and small t trauma
In medicine, we recognize ‘big T’ and ‘small t’ trauma. Big T Trauma is typically exposure to extremes where loss of life or limb are possible. Think of soldiers in warzones. Think of Law Enforcement and First Responders. Think of ER staff fearing for their lives when an enraged gunman opens fire.
Small t trauma, which I call ‘micro trauma’ may not endanger us, so is often underestimated, but it is endemic to medicine:
- caring for oh so many patients who are the victims of violence, abuse, and neglect (by partners, employers, the government);
- witnessing bullying (it happens in healthcare — often);
- seeing so many patients suffer and die (and the effect on their loved ones);
- the moral injury of working in systems which put profits before patients, cut costs which reduce care, and brazenly exploit the good- natured giving personality of their staff;
- being sued
- all of the other life events that happen to normal people outside the hospital: births, deaths, marriages, divorces, job changes, etc.
All of these increase stress hormones like cortisol, which in turn raised blood pressure and causes central fat buildup as well as numerous other undesirable effects.
Small t trauma may not have the same extremeness or risk to life as Big T trauma, but over time, the t’s all add up.
I don’t think we recognize just how much “small t” trauma exists in the healing professions.
Trauma exposure starts early
As physicians, we face trauma. We must learn how to care for ourselves first, in order to care for others.
We are exposed to a number of types of trauma on a daily basis in our roles as caregivers. And while these experiences can be difficult to process individually, they can also cause long-term mental health consequences when they are experienced repeatedly over time.
“It is our mission here… to rigorously and ruthlessly train the humanity out of you… and make you into something better… We’re gonna make doctors out of you.” — Dean Walcott, Patch Adams (movie)
But trauma exposure starts surprisingly early in our medical training. From expectation-setting in the first days at med school (see quote below) to cutting up dead people (in anatomy class), to exposure to the chaos of clinical attachments, to the first years as a young doctor navigating the corridors of the hospital, where your decisions could literally mean life or death for dozens of people.
In a recent support group for doctors, one MD described being alone in an ER where there was 1 doctor and 3 simultaneous ‘codes’ (where patients have stopped breathing or are dying acutely) — a heart attack, a stab chest, and a respiratory arrest (stopped breathing). How do you choose? How can a human being be expected to make these choices about who gets to live?
Now imagine this and multiply by 100,000 to represent the awful dilemmas of COVID.
As a result of this exposure to trauma — and perhaps because we already tend to be analytical thinkers who take pleasure in solving problems — physicians may be particularly susceptible to developing post-traumatic stress disorder (PTSD) and burnout than other professions might be.
Consequences of trauma
The trauma of medicine can be overwhelming.
In fact, according to one study published in the Journal of Traumatic Stress Injury & Violence Prevention found that rates of both PTSD and burnout were significantly higher among physicians compared with those working across other industries like finance or banking; another study showed that 80% of physicians surveyed had experienced at least one traumatic event during their education or training programs — yet less than half ever sought treatment for these symptoms.
A recent paper in the European Journal of Psychotraumatology reported that, during the first wave of the pandemic, 22% of all UK medical staff met the diagnostic criteria for post-traumatic stress disorder, and 47% for depression or anxiety. That’s 1 in 5 for PTSD and nearly 1 in 2 for depression/anxiety.
The highest risk factors were among those who were concerned about infecting others, who felt stigmatized, who could not talk with their managers if they were not coping, and who had not had reliable access to personal protective equipment (PPE). Who sends their soldiers into battle without the right equipment?
And we know that medical staff are the worst at reaching out for help.
Perhaps not immediately, but over time the traumas can add up, especially if they are not dealt with at the time.
In surveys of physicians pre- and post-COVID:
- 40–80% had moderate or severe burnout (more post COVID and in higher-intensity specialisms like ER and Respiratory medicine);
- 28% reported experiencing at least one traumatic event during medical school; and
- 15% screened positive for PTSD (compared to 7% among non-medical student controls).
Stress vs burnout vs PTSD
The general public is often unaware of the trauma physicians experience on a daily basis. Because of the nature and unpredictability of their jobs, doctors are much more likely to experience traumatic events than people in other professions. This exposure can have detrimental effects on both mental and physical health.
It is also important not to confuse stress, burnout and PTSD; although it may be true that the former sometimes causes one or more of these disorders, they are essentially different conditions.
Stress can be a positive or negative experience, depending on the demands one encounters throughout his or her lifetime. The stress response is a physiological reaction that prepares the body for action in the face of perceived danger. The body’s stress response usually turns off once the stressful situation ends. Toxic stress responses include a prolonged or permanent physiologic response to a stressor that can cause damage to vital organs.
Burn-out is a psychological syndrome that occurs when people are unable to deal effectively with the stress of their work. It manifests itself in three ways: feelings of being worn out, mentally distant from one’s job or feeling cynical about it.
PTSD is a diagnosable mental health condition. The symptoms of PTSD can begin immediately after the event that triggers it, or they can be delayed for several weeks or months. Commonly reported symptoms include traumatic flashbacks, avoidance behavior, and increased arousal and agitation.
So, what can be done? The evidence base for prevention of traumatic consequences in physicians is scant.
Stress reduction for physicians
Several studies have investigated stress-reduction techniques for physicians. The overall findings of these investigations are that cognitive, behavioral, and mindfulness interventions are associated with decreased anxiety and burnout among medical professionals.
Examples of interventions include behavioral stress management workshops, goal prioritization and relationship building.
Multiple randomized controlled trials have demonstrated that mindfulness techniques reduce stress biomarkers and improve positive state-of-mind, distress, rumination and burnout scales — all with positive results.
As physicians, we face trauma. We must learn how to care for ourselves and others.
Conclusion
Trauma and medicine are inextricably linked. As physicians, we must face our own trauma head on. We must continue to work with patients who have experienced trauma, and our own trauma from working in medicine. Self-care, stress management, and stress reduction techniques may help us cope better. These skills should be taught in medical school and supported throughout a physician’s career.
Thanks for reading!
DC
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