On Friday, June 11, 1982, members of the faculty met to discuss the performance of the psychiatric residents over the past six (6) months. The following is a summary of their comments that apply to your performance.
The faculty response to your performance was unanimously excellent. There was some comment about your previous fear of the psychotherapeutic role, but the consensus was that this has improved significantly and you are now more comfortable to the obvious delight of your faculty. There were comments about the diligence of your reading in the field and there were quotes like ‘first class’, ‘great’, ‘a good teacher’.
Art, the comments speak for themselves. We are delighted with your achievements over the past year and consider you an outstanding resident. I am pleased with this report and look forward to your continuation in this direction in the next academic year.
Professor and President
Department of Psychiatry
I received that letter over 40 years ago, at the end of a hellish second year of residency. Unknown to all but my husband and psychiatrist, I was recovering from the effects of “vicarious” or “secondary” trauma, determined as “the destructive emotional distress resulting from an encounter with a traumatized and suffering patient or client who has suffered primary or direct trauma.”
Only in my case I didn’t have a direct encounter, at least not technically, because I never got to know the patient who had traumatized me.
In the spring of 1981, near the end of my first year of residency, I was “on call” and asked to give an opinion on an emergency department (ED) patient who was “hearing voices.” The ER resident wanted my advice on his medication, but she said there was no need to come to the ER to evaluate him. After assuring me over the phone that the patient was not dangerous, I suggested she increase his dose of haloperidol.
The patient was discharged, but he returned to the ER several hours later after attempting suicide – the patient had jumped from the third floor window of his boarding house. He survived the fall, but suffered significant orthopedic injuries.
I blamed myself for the incident and succumbed to the moral injury of violating my personal code of excellence. “I should have seen the patient,” I thought. My injury was compounded by shame and guilt as news of what had happened quickly circulated among the household staff. I slipped into a deep depression, barely able to function.
My PGY-II mid-year (December 1981) evaluation was so bad that I was put on probation. It was clear that 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 fall from grace was cemented after one of the faculty members—the person who actually interviewed me and recommended me for admission to medical school—told me there was no way I could “sugarize” my abysmal performance.
Psychotherapy saved my life and enabled me to complete my residency, and even regain my star status as Chief Resident. But I was never able to overcome the “fear of the psychotherapeutic role” referred to in my chairman’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 result in a fatal or near-fatal outcome and put another blemish on my record.
As a form of self-therapy I published a “coming out” article about the incident, albeit 33 years after it happened. I was humbled by the many doctors who responded to the article and shared similar experiences of vicarious traumatization.
An obstetrician-gynecologist wrote: “I, too, have a memorable patient whom I never saw when I was in training, and I continue to feel waves of shame and sadness over the outcome that could have been avoided had I not gone back to sleep when the resident assured me that it was not necessary for me to see the patient.”
A colleague confided in me that when he was a resident and moonlighted in a crisis center, he evaluated and fired a man who went home and killed his partner. The murder was covered by the local newspaper and television stations. My colleague escaped mention, but he was crushed by the ordeal, plagued for months by intrusive memories and disrupted sleep – signs and symptoms typical of PTSD.
It is rarely realized that physicians exposed to traumatic events or trauma survivors can become traumatized themselves – approximately 10 to 20 percent develop PTSD. Surgeons and emergency room doctors tend to have it higher rates of PTSD for obvious reasons: they treat a disproportionate number of traumatically injured patients. Psychiatrists and psychotherapists are susceptible because their patients discuss aversive details of traumatic experiences during therapy.
Doctors traumatized by unexpected outcomes such as death; surgical complications; medical errors, mistakes and setbacks; and malpractice lawsuit can also develop PTSD. These doctors often consider themselves “innocent bystanders” of trauma. Nevertheless, the emotional impact can be severe and long-lasting.
One doctor who wrote to me recalled being traumatized by a malpractice lawsuit and even more traumatized when his attorney pressured him to settle. Not “getting his day in court,” where he was assured 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 after exposure to trauma. The corona pandemic is considered a traumatic stressor and is the reason about 20 percent of physicians plan to leave the practice within two years. Many physicians feel they have been pushed to their limits, traumatized by a variety of practice-related stressors, not least of which is working in a dysfunctional health system where the threat of violence is greatmaking them susceptible to both indirect (vicarious) and direct (physical) trauma.
While medical students often think they are experiencing the symptoms of an illness they are studying, once they enter the practice, students are at real risk for PTSD. My practice days were out of residence for over a decade. I sought less stressful jobs in manufacturing – pharmacy and health insurance – and never looked back.
Yet every spring evokes a jubilee response. I think of the “jumper” and wonder, “What if?”
Arthur Lazarus is a psychiatrist.
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