Dear Art:
On Friday, June 11, 1982, faculty members met to discuss the performance of psychiatry residents over the past six (6) months. The following is a summary of their comments as they apply to your performance.
Faculty response to your performance was uniformly excellent. There were some comments about your earlier fear of the psychotherapeutic role, but the consensus was that it has improved markedly and you have now become more comfortable with the obvious enjoyment of your faculty. There were comments about how diligently you read in the field and there were quotes such as “topnotch”, “tremendous”, “a good teacher”.
Art, the comments speak for themselves. We are delighted with your performance over the past year and consider you an outstanding resident. I welcome this report and look forward to your continuing to do so in the next academic year.
Best wishes.
Cordially,
[Name Withheld]
Professor and President
Department of Psychiatry
I received this letter over 40 years ago, at the end of a second year of infernal residence. Unknown to all but my wife and psychiatrist, I was recovering from the effects of “vicarious” or “secondary” trauma, defined as “the destructive emotional distress resulting from an encounter with a traumatized and suffering patient or client who has suffered primary or direct trauma. trauma.”
Only in my case, I didn’t have close contact, at least not technically, because I never knew the patient who traumatized me.
In the spring of 1981, near the end of my first year of residency, I was “on call” and asked to comment on an emergency department (ED) patient who was “hearing voices.” The ER resident wanted my opinion on her medications, but she said there was no need to come to the ER to assess her. After assuring me over the phone that the patient was not dangerous, I suggested that he increase his dose of haloperidol.
The patient was discharged, but returned to the emergency room several hours later following a suicide attempt – the patient had jumped out of the third floor window of his boarding house. He survived the fall but suffered significant orthopedic injuries.
I blamed myself for the incident, succumbing to the moral injury of violating my personal code of excellence. “I should have seen the patient,” I thought. My hurt was compounded by shame and guilt, as news of what had happened quickly spread among the staff at the house. I slipped into a deep depression, barely able to function.
My mid-year PGY-II evaluation (December 1981) was so bad that I was put on probation. Obviously, I was not a rising star in the eyes of the faculty, some of whom had known me since I was a medical student. My disgrace was cemented after one of the faculty members – the person who interviewed me and recommended me for admission to medical school – informed me that there was no way to “salute” my catastrophic performance.
Psychotherapy saved my life and allowed me to complete my residency, even regaining my star status as Chief Resident. But I was never able to overcome the “fear of the psychotherapeutic role” mentioned in my president’s letter. Each new encounter with a patient increased my anxiety. What if they were suicidal? What if they were dangerous and hurt someone? I couldn’t bear the thought of being responsible for someone’s actions that could have a fatal or near-fatal outcome and cause another stain on my record.
As a form of self-help, I published a “coming out” article about the incident, albeit 33 years after it happened. I was touched by the many doctors who responded to the article and shared similar experiences of vicarious trauma.
An obstetrician-gynecologist wrote: “I too have a memorable patient I never saw when I was in training, and I continue to feel waves of shame and sadness at the outcome that would have could have been avoided if I had not gone back to sleep. when the resident assured me that I did not need to see the patient.
A colleague said that when he was a resident and moonlighter at a crisis center, he assessed and fired a man who came home and killed his girlfriend. The homicide was covered by the local newspaper and television stations. My colleague escaped mention, but he was crushed by the ordeal, plagued by intrusive memories and disturbed sleep for months afterwards – typical signs and symptoms of PTSD.
It is rarely acknowledged that physicians who are exposed to traumatic events or trauma survivors can, themselves, become traumatized – approximately 10-20% develop PTSD. Surgeons and emergency physicians tend to have higher rates of PTSD for obvious reasons: they treat a disproportionate number of trauma patients. Psychiatrists and psychotherapists are susceptible because their patients discuss aversive details of traumatic experiences during therapy.
Doctors traumatized by unforeseen events such as death; surgical complications; medical errors, errors and mishaps; and malpractice litigation can also develop PTSD. These physicians often see themselves as “innocent bystanders” to trauma. Nevertheless, the emotional impact can be severe and long-lasting.
A doctor who wrote to me recalled how he had been traumatized by a malpractice lawsuit and even more traumatized when his lawyer pushed him to settle it. Not “having his day in court”, where he was certain he would be vindicated, contributed significantly to his PTSD and “emotional inability to stay in practice”.
It may be impossible for doctors to function normally again after exposure to trauma. The coronavirus pandemic has been seen as a traumatic stressor and is the reason around 20% of physicians intend to leave practice within two years. Many physicians feel pushed to their limits, traumatized by a variety of practice stressors, including working in a dysfunctional healthcare system where the threat of violence looms large, predisposing them to both to indirect acts (by proxy) and direct trauma (bodily).
While medical students often perceive symptoms of an illness they are studying, students are at real risk for PTSD once they start exercising. My days of practice lasted less than ten years away from residence. I looked for less stressful jobs in industry – pharmaceuticals and health insurance – and never looked back.
Yet every spring invokes an anniversary reaction. I think of the “sweater” and I wonder, “What if?”
Arthur Lazare is a psychiatrist.
Image credit: Shutterstock.com
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