By SUZAN SONG MD, MPH, PhD
The U.S. now has the highest number of COVID-related deaths in the world, with exhausted, frightened physicians managing the front lines. We need not only medical supplies but also emotional personal protective equipment (PPE) against the psychological burden of the pandemic.
As a psychiatrist, my role in COVID-19 has included that of a therapist for my colleagues. I helped start Physician Support Line, a peer-to-peer hotline for physicians staffed by more than 500 volunteer psychiatrists. Through the hotline and social media, physicians are revealing their emotional fatigue. One doctor shared her sense of powerlessness when she couldn’t provide comfort but instead had to watch her young patient with COVID-19 die alone from behind a glass window. Another shared his sorrow after his 72-year-old patient died by suicide. She was socially isolated and didn’t want to be a burden on anyone if she contracted COVID-19. An internist felt deep distress and alarm that her hospital was quickly running out of ventilators and had 12 codes in 24 hours.
Through a brief survey I conducted across the U.S., 269 physicians reported moderate to severe symptoms of anxiety (53%), depression (43%), and insomnia (16%). About 46% wanted to see or would consider seeing a mental health clinician for severe anxiety (30%), not feeling like themselves (27%), or being unhappy (21%). These are all similar statistics to the front line health care workers in Wuhan.
Physicians are overwhelmed by death, uncertainty, and patients’ fears as they struggle to live. We are witness to the helplessness that families and loved ones feel, and powerless in our ability to protect without the proper equipment or directives from administrators. We feel the deep sense of aloneness leaving a hospital shift to return to a home in which we may be responsible for getting loved ones sick.
These are all parts of vicarious trauma – the emotional residue of witnessing the pain, fear, and terror, that trauma survivors have endured. Vicarious trauma is one of the occupational hazards of working in a pandemic. People feel emotionally numb or shut down, have difficulty sleeping, feel more irritable or use destructive coping (over/under eating, substance abuse, engaging in risky behavior), lose a sense of meaning in life or feel hopeless about the future, and can experience relationship problems.
But our psychological burden isn’t only from the vicarious trauma of witnessing despair. The lack of available masks, slow and inadequate testing, poor executive leadership, ill-informed and potentially harmful guidance, and punitive behavior by some hospital administrators towards those who have raised concerns about public health safety, have inflicted moral injuries when we have to make ethical decisions around resource scarcity. Who gets put on a ventilator? Who gets to wear the PPE? How do we let people die alone without anyone by their side? How do we choose which patients to treat? By age? By co-occurring diseases? By COVID-19 positive status? The answers to these will challenge our “do no harm” ethical principle, as someone will suffer and potentially die because of our decisions.
Moral injury, initially defined by researchers from veterans hospitals, refers to the emotional, physical, and spiritual harm people feel after perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations. It’s when we have to comply with policies that we fundamentally disagree with, putting us in difficult ethical challenges.
Physicians aren’t new to rationing in the health care system. MRIs aren’t ordered on every lower back pain or headache. We know how to manage illness, and while this is a new coronavirus, our colleagues in China and Italy have shared clinical management protocols. But mixing moral injury with vicarious trauma will lead to physician burnout.
We need to “do no harm” by providing emotional personal protective equipment (PPE), in addition to appropriate medical PPE. Now isn’t the time to cut compensation to our front line physicians or turn away skilled physicians due to our fears of living near doctors. We need to build transparency, communication, and collaboration between physicians, administrators, and leadership. All health care systems should be prioritizing trust and togetherness through a clear mechanism of soliciting perspectives and feedback without fear of punishment for raising concerns. We need more guidance on rationing, so we don’t worsen disparities, and ensure physicians are supported to make these difficult ethical decisions. We should ease the emotional burden that physicians face, to equip them with the moral courage to save lives in this pandemic and to endure the inevitable losses to come.
Suzan Song, MD, MPH, PhD is a Harvard and Stanford trained psychiatrist, currently Director of the Division of Child/Adolescent & Family Psychiatry and Associate Professor at George Washington University Medical Center.