For weeks, the news has been all about COVID-19 and its impact beyond Wuhan, where it emerged. Just two days ago, in fact, the first case reports surfaced in the county where I live. Overnight, preparations have leapt a notch. Many will work from home. Students will learn online. Even the gym where I climb with my son e-mailed regarding steps to minimize transmission. Like most of you, however, by caring for the sick, I am virtually certain to be exposed.
This is nothing new. Our work exposes us to so much. And honestly, I think that injury from COVID-19, while immediate and concrete, is, in many ways, the least among risks we run. By virtue of our commitment to humanity, we encounter an array of injuries that can impact on our health, joy, and longevity.
In the course of my travels, virtual and “in real life,” I’ve discovered that while many of us intuitively know that these injuries exist, we mostly lack a clear, shared vocabulary to define them. That matters. Like all injuries, the better we define them, the greater the likelihood we’ll heal. So, let’s explore. Let’s look at four of the injuries embedded in our work for millennia, regardless of what’s in the news today.
1. Secondary trauma
It goes without saying that our work exposes us to human suffering. We knew that going in, right? Most of us entered medicine to aid the vulnerable. What many of us may not have foreseen is how that would affect us.
When that impact injures us, the term “trauma” often applies. When we see something disturbing which we cannot unsee, the trauma is “primary.” According to Dr. Patricia Fisher, however, in cases where we hear a detailed account, the injury becomes “secondary” or “vicarious.” Essentially, our very strength — our empathy — makes us vulnerable to the ripple effects of another’s trauma.
Repetitive secondary trauma has the potential to result in a complicated emotional stew and a “profound shift in world view … (in which) helpers notice that their fundamental beliefs about the world are altered and possibly damaged.”
Trauma can heal. However, unaddressed, those changes stand to harden and sadden us, robbing us of joy in our calling and connection with humanity. And that can shorten our professional and personal longevity.
2. Becoming a second victim
I write and often speak about my experience of becoming what some call a “second victim.” Along the way, I’ve realized that many people use the terms “second victim” and “secondary trauma” as if they were interchangeable. They are not.
According to Sidney Dekker — pilot, safety scientist, and one of the leading experts in this domain — the term “second victim” refers to a person who is injured when someone they seek to heal or protect is harmed or nearly so, and crucially, that person wonders whether something they did or didn’t do was causative. Although the term “second victim” is somewhat controversial, I like it, because it highlights the fact that certain events inherent to our work can injure us as well.
Like those impacted by vicarious trauma, second victims also experience a distressing whirlwind of emotions and physical sensations. There is, however, a distinct quality to their moral distress brought on by the questions they harbor around the nature of their responsibility for harm or near-harm to another human being. This moral distress can result in lasting sensations of guilt, shame, and loss of self-worth, all of which can increase suicide risk. The path to healing differs from that of secondary trauma.
3. Enduring an investigation
In this research, the authors found enduring the subsequent investigation to be one of the most grueling phases of recovery for second victims. That makes sense. By definition, the second victim struggles with questions of culpability, competence, and personal value. Having outsiders meticulously question whether they are solely and individually responsible for what is usually a systems failure is excruciating, often heaping one injury upon another.
Second victims are not the only ones injured by investigation, however. In the U.S., physicians are frequently subject to the stresses of medical malpractice litigation even when they feel certain that their care was appropriate. The resulting sensation that the stress of investigation can arise randomly provokes PTSD-like symptoms and anger for physicians in both groups, impacting upon their capacity to enter into caregiving wholeheartedly and non-defensively.
4. Moral injury
In 2018, Wendy Dean and Simon Talbot lit a fire under our communal conversation around physician burnout by injecting the term “moral injury.” In a powerful opinion piece, they argued that much of physician burnout stems from our sense that we cannot do right by our patients. Like military veterans, it harms us, they argued, to be continually caught between our deep moral commitments and the flaws in the healthcare system. On the one hand, we have profound knowledge regarding what would benefit our patients, and on the other, systemic issues profoundly constrain our capacity to take action on behalf of our patients’ welfare.
I don’t side with those who argue that all physician burnout is due to moral injury; I’m not sure Dean and Talbot would argue that either. I do believe it’s a crucial factor, however. It’s my sense that our burnout stems from a mix of all of these injuries and then some, in varying proportions, for each of us according to our unique professional history and experience.
One thing these injuries have in common is their capacity to provoke shame and anger, both of which feed on isolation. Connecting to share our stories, on the other hand, is a major super-power.
By coming together, we free ourselves to heal.
We have worked long and hard to engage in one of the most meaningful tasks in the world — loving humanity through healing others. Let’s come together in mutual support to ensure that nothing robs us of our love for our extraordinary calling.
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