I was on my honeymoon in Colombia when I first became aware of the true extent of my post-traumatic stress disorder. My husband and I were walking across a smooth, granite platform to take a closer look at a fountain in downtown Cartagena. As we neared the structure, mist from the fountain’s jets dampened the ground at my feet.
I froze, paralyzed with fear by a flashback — my first — triggered by something as ordinary as wet pavement on a warm day.
Two years earlier, I was working in civic engagement efforts in Baghdad. One morning, as I walked across a smooth, granite platform toward my apartment, gunfire erupted. I tried to run, but my flip-flops bested me on the pavement, still damp from an early mopping. I slipped and fell backward, hitting my head hard enough to knock me out. When I opened my eyes minutes later, the platform was covered with my blood.
That happened 15 years ago this week, those Ides of March when American forces invaded Iraq.
Back home in the U.S., it was clear to those around me that I had PTSD. It wasn’t until six months after my honeymoon, however, that I had the courage to acknowledge that I needed help. It’s not easy seeing your own weaknesses, much less conceding them. But when my habitual glass of wine with dinner became a bottle, and fireworks left me sore and sleepless for days, it was hard to fight the signs.
Celexa for guilt. Ambien for sleep. Therapy for months. My psychologist and primary care physician spoke regularly to coordinate my care. Most importantly, family and friends became members of my care team. Isolation is a trauma victim’s ill-advised drug of choice, one my loved ones and clinicians wouldn’t let me take.
Trauma in health care
Some people who contract a disease become experts in it. I’m one of them. We obsess over the research. We learn the signs and symptoms, and develop a private language with our fellow patients. We learn each other’s triggers and tactics, like an army of code talkers who just … know.
Which is why today, as a health care advocate who has struggled with PTSD, it’s clear to me that many of our country’s health care providers are struggling with trauma, as well. And we’re doing little to support them.
A few weeks ago, I was talking with a physician who served our country in Iraq. We chatted nostalgically about the taste of sand and shawarma before he said something that gave me pause: “You know, I’d go back to the field any day. Beats practicing in my clinic.”
“Why’s that?” I asked.
“I didn’t become a doc to put up with billing codes and power struggles. I thought that PTSD would hit when I came home from Fallujah. It’s so much worse when I come home from the office. Truth is, I’ve lost my sense of purpose.”
That struck a chord.
Clinicians are experiencing epidemic rates of what we casually call “burnout,”with such symptoms as fatigue, irritability, and stress — like we’re talking about the trials of new parenting.
But there’s something beyond burnout happening in health care today. More than half of primary care physicians are at the end of their ropes. Nearly 1 in 3 resident physicians have symptoms of depression. One in 10 medical students have thoughts of suicide. They’re not stressed out or, as my family was fond of saying about me, “adjusting.” They’re experiencing trauma — that loss of meaning cited by the army medic.
“Tiny betrayals of purpose”
Clinician burnout is frequently chalked up to the eight-minute visits with patients, the six hours spent each day entering data into electronic health records, and the demands of a profession where life-and-death decisions must routinely be made. But this short list of factors doesn’t get to the real wounds of practicing medicine .
In an article in the Atlantic, Dr. Richard Gunderman offers a more nuanced breakdown of causation. He notes that “burnout at its deepest level is not the result of some train wreck of examinations, long call shifts, or poor clinical evaluations. It is the sum total of hundreds and thousands of tiny betrayals of purpose, each one so minute that it hardly attracts notice. [Physicians] find themselves expressing amazement and disgust at how far they’ve veered from their primary purpose.”
Gunderman isn’t the first to explore the cumulative impact of these “tiny betrayals of purpose.” In his book “Achilles in Vietnam,” Dr. Jonathan Shay, a psychiatrist who studied Vietnam veterans, made the case that actions that contradict an individual’s core purpose — either compulsory or voluntary — can result in a kind of “undoing of character.” For clinicians, much like combat veterans, these violations of character can build up, with damaging consequences.
It’s not just the eight-minute visit: It’s that an eight-minute visit means physicians can’t provide whole-person care to patients whose diagnoses aren’t easily logged into a computer. It’s not just the six hours of daily data entry: It’s that it takes clinicians’ eyes off their patients, missing the very connection with humanity that drove them into this work. And it’s not just the problematic quality metrics that physicians are subjected to: It’s that those metrics have crowded out deeper connections with patients to help them manage triggers and navigate treatment.
During grand rounds at Duke University School of Medicine, Dr. Andrew Morris-Singer, a leading voice on physician burnout and an advocate for primary care reform, remarked that the state of the system is resulting in a generation of clinicians practicing medicine “in a manner inconsistent with their values.” The results of this inconsistency can be fatal. More than 400 providers take their lives each year — an industry suicide rate second only to the armed forces. If thatdoesn’t compel us to act, then the impact of burnout on patients should ignite a national conversation. Clinicians with mental health challenges make more mistakes, take more sick days, are less engaged in their work, and are less empathetic.
It’s time to call burnout what it really is: trauma. As I and so many others who have experienced trauma have come to realize, its sufferers don’t always see the signs. Health care providers are no different. Others need to help them see what they are experiencing. That job needn’t fall solely to their family members or colleagues. Patients — you and me — need to step up and call it out, to demand action by health care organizations to address it, and to offer a community of care that serves as a powerful antidote to isolation and retreat.
If we don’t, if we continue to disregard the epidemic of trauma among our physicians, lives — of patients and providers — will be unnecessarily lost.
During a panel at last year’s Aspen Ideas Festival, Morris-Singer offered a simple challenge: “The next time you wrap up a visit with a health care provider, ask him or her, ‘How are you doing?’”
I echo that. Let’s start a conversation with our health care providers and listen, really listen, to their needs. As William Osler, father of modern medicine, famously remarked, “Listen to your patients. They are telling you their diagnosis.” Clinicians, too, are telling us their diagnosis. It’s time we responded.
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