Anniversaries are usually joyous occasions to celebrate – a wedding date or a date of independence, for example. Other anniversaries invoke solemn occasions, such as the end of a war or 9/11 after the bombing of New York. But there is another type of anniversary some of us in the medical profession commemorate because each year it reminds us of a traumatic experience we endured earlier in our career, often as medical students or residents, when we were the so-called “secondary” victims of trauma, also referred to as vicarious trauma.
I became interested in this topic because I was a victim myself – I suffered considerable anxiety and depression after the suicide attempt of a patient. The emotional repercussions were so severe it caused me to prematurely leave practice. I researched vicarious trauma in health care providers and found very little information on the topic. However, the few publications that existed did confirm that certain physicians were at higher risk of suffering psychiatric sequelae of trauma related to death, medical error, malpractice litigation, and other stressors.
I broadened my search and discovered vicarious trauma is an occupational challenge for people working and volunteering outside of medicine in the fields of social services, law enforcement, fire services, and other professions, due to their continuous exposure to victims of trauma and violence. Individuals in those occupations suffer a fate similar to physicians, with consequences ranging from burnout to depression to PTSD. Although the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not specify events related to medical practice as stressors sufficient to cause PTSD, it does recognize “repeated or extreme indirect exposure to aversive details of a traumatic event” as a qualifying stressor.
Yet, the prevailing medical culture seems to deter physicians from effectively dealing with the challenging emotions that naturally arise when confronted by patients facing death, trauma, accidents, and life-threatening illnesses – never mind bearing witness to severe human suffering. This is especially demoralizing in this critical time of pandemic. As an avid reader of medical blogs, I have witnessed many callous and unsympathetic remarks aimed at physicians seeking support and therapeutic relief by sharing their personal experiences online, experiences related not only to the pandemic but also to everyday interactions with patients and families apart from COVID-19.
In one account, for example, an infectious disease specialist described how she gave a patient with an ominous pulmonary infection the best possible care, yet the patient died – not an uncommon experience for doctors. While the overwhelming majority of reactions to her essay were supportive and praiseworthy, one physician, a psychiatrist no less, was harsh and critical of the doctor, opining she did only “a minimal average acceptable job…[with] no clue whatsoever if the standard of care was met.”
The same physician also attacked me, insinuating that I had financial or other conflicts of interest simply for recommending that primary care physicians use mental health screening tools in their practice – screening instruments that are in the public domain, for which I receive no compensation. He was rude to another physician author who wrote an article discussing several ways physicians can supplement their income – the physician dismissed the article as “utterly useless.” However, in researching this individual’s background, I found no original compositions penned by him. He is what we refer to in the vernacular as an internet “troll”: a person who posts inflammatory, insincere, disruptive, digressive, extraneous, or off-topic messages in an online community. There is no place for trolls in a therapeutic – or any other – community.
Surprisingly, some of my most heartfelt editorials have been the target of uncivil physicians, and lately I find myself at a war of words with a few colleagues who I only know by their online profiles. In several instances, I have had to notify the editors of blogs that I believe their remarks constitute infractions of community standards, and I asked that the offending comments be removed (sometimes they were). Aggressive, unwarranted character attacks compound any past trauma physicians may be dealing with and trying to overcome by off-loading their angst on their peers. Hostile and loathsome comments designed to undermine a physician’s integrity are unprofessional and unwelcome, to say the least.
Even playful remarks made in jest may be viewed as taunting and teasing. When one such comment was directed my way, the commenter was taken to task by a community peer, who defended me and replied to the physician, “I must say that among your many comments that I encounter on[line], you always seem to find some way to poke your fellow clinicians’ egos.” Rule number one when posting online is that comments should be phrased toward fostering productive and meaningful conversations with other community members. It’s axiomatic that if you can’t say anything nice, don’t say anything at all.
When physicians write about highly charged, potentially traumatic experiences they’ve encountered in the course of clinical practice and share their stories online, they often seek solace and redemption through a community of like-minded peers. Narrative medicine catalyzes a much-needed conversation about professional grief and trauma by including thoughtful essays (and poems), writing prompts, and community responses and discussion. Most physicians are sincere in their comments, but there are few bad actors who are unforgiving and unprofessional. They add another layer of burden to physicians already predisposed to stress and vulnerable to trauma.
It is well known that secondary exposure to patients’ trauma can negatively affect the quality of care and professional well-being. Let’s not also incorporate physicians’ behavior into that mix of trauma. Physicians need to constructively engage with each other lest they begin to internalize their trauma, stop writing (or speaking), and suffer in silence.
Arthur Lazarus is a psychiatrist.
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