On Friday, June 11, 1982, faculty members met to discuss the performance of the psychiatric residents over the past six (6) months. The following is a summary of their comments as they relate to your performance.
The faculty’s response to your performance has been consistently excellent. There were some comments on your previous anxiety about the psychotherapeutic role, but the consensus was that this has improved significantly and that you are now more comfortable with your faculty’s apparent enjoyment. There were comments about the care you took in reading this section and there were quotes like “excellent”, “great”, “a good teacher”.
Art, the comments speak for themselves. We appreciate your performance over the past year and think you are an outstanding resident. I am delighted with this report and I look forward to seeing you continue in this direction in the next academic year.
professor and chairman
Department of Psychiatry
I received this letter over 40 years ago, at the end of a hellish sophomore year. No one but my spouse and psychiatrist knew that 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 is primary or directly suffered trauma.”
Only in my case I didn’t have a close encounter, at least not technically, because I never got to know the patient who traumatized me.
In the spring of 1981, near the end of my first year of residency, I was “on call” requesting an opinion on an Emergency Department (ED) patient who was “hearing voices.” The ER resident wanted my advice on his medication, but she said it was not necessary to come to the ER to examine him. After reassuring myself over the phone that the patient was safe, I suggested that she increase his haloperidol dose.
The patient was discharged, but he returned to the emergency room a few hours later after attempting suicide — the patient had jumped from the third-story 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 offense 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 circulated among the domestic workers. I slipped into a deep depression, barely able to act.
My mid-year (December 1981) PGY-II score was so bad that I was placed on probation. Obviously, I wasn’t 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 that there was no way I could “gloss over” my miserable performance.
Psychotherapy saved my life and enabled me to complete my residency and even regain my star status as a senior resident. But I was never able to overcome the “fear of the psychotherapeutic role” referred to in my chairman’s letter. Every encounter with a new patient increased my anxiety. What if they had suicidal thoughts? What if they were dangerous and harmed someone? I couldn’t bear the thought of being responsible for someone’s actions that could lead to a fatal or near-fatal outcome and leave another stain on my record.
As a form of self-therapy, I published a “coming out” article about the incident, albeit 33 years after the incident. I was impressed by the many physicians who responded to the article and shared similar experiences with vicarious trauma.
One obstetrician-gynecologist wrote: “I too have a memorable patient whom I never saw during my training and I continue to feel waves of shame and sadness at the outcome which could have been avoided had I not gone back to sleep when the.” resident assured me that I did not need to see the patient.”
A colleague confided that when he was a resident and undeclared worker at a crisis center, he investigated and released a man who went home and killed his partner. The murder was reported by the local newspaper and television stations. My colleague escaped mention, but he was crushed by the ordeal, plagued by intrusive memories and having trouble sleeping for months afterwards – signs and symptoms typical of PTSD.
It is rarely recognized that physicians exposed to traumatic events, or trauma survivors themselves, can become traumatized – approximately 10 to 20 percent will develop PTSD. Surgeons and emergency physicians tend to have higher rates of PTSD for obvious reasons: They treat a disproportionate number of traumatically injured patients. Psychiatrists and psychotherapists are vulnerable because their patients discuss aversive details of traumatic experiences during therapy.
Doctors traumatized by unexpected consequences such as death; surgical complications; medical errors, errors and mishaps; and misconduct lawsuits can also develop PTSD. These doctors often see themselves as “innocent bystanders” of the trauma. Still, the emotional impact can be severe and lasting.
A doctor who wrote to me recalled being traumatized by a malpractice lawsuit and even more traumatized when his attorney pressured him to settle it. Failure to “get his day in court” where he was sure he would be rehab greatly contributed to his PTSD and “emotional inability to stay in practice.”
It can be impossible for doctors to function normally again after trauma. The coronavirus pandemic is considered a traumatic stressor and is the reason why about 20 percent of doctors intend to leave the practice within two years. Many physicians feel pushed to their limits, traumatized by a variety of practice-related stressors, not the least of which is working in a dysfunctional healthcare system where the risk of violence is high, predisposing them to violence both indirect (vicarious) and direct (physical) trauma.
While medical students often feel they are suffering from the symptoms of a disease they are studying, students are at real risk of developing PTSD once they enter practice. My practical days were away from the residency for less than ten years. I looked for less stressful jobs in industry – pharmaceutical and health insurance – and have never looked back.
Yet every spring evokes a jubilee reaction. I think of the “Jumper” and wonder, “What if?”
Arthur Lazarus is a psychiatrist.
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