DOUBLE LIFE:

RETURNING FROM EXTREMES OF EXPERIENCE

For clinicians, what is the internal experience of returning to relative normality (in both professional and personal life) after an intensely emotional work-related event? How do physicians uniquely experience life’s “undulations,” and what elements of doctors’ individual constitutions and identities most inform that experience?

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The American Association of Nurse Anesthesiology defines a “critical event” in medical practice as a “powerful and overwhelming event…outside the range of usual human experience” with “potential to exhaust one's usual coping mechanisms” (1). Most providers experience at least one such event in their careers. As one physician practicing at Johns Hopkins recently noted, “it’s not a matter of if clinicians are going to experience trauma while providing care—but when and how often" (2). Historically, providers have been expected to maintain “stoicism” in the face of emotional turbulence; given the force and ubiquity of critical events, however, it is vital to acknowledge the robust, lasting nature of the emotional responses they can provoke (2,3).


Emergency Medicine physician Edwin Leap, MD describes the “serious emotional roller coaster” of “laugh[ing] with one patient, comfort[ing] another, sav[ing] another and los[ing] another” all in a relatively short period of time (4). Some clinicians may jump rapidly between critical events in a single day; others may experience stretches of “mundane” or even lighthearted work that throw critical events into stark relief. And just as the emotional “path” of medical practice is unique for every clinician, so too is every provider’s response to, and ability to cope with, critical events. A misconception exists that doctors are trained to handle emotional turmoil—that they are somehow “immune from the impact of practicing medicine,” capable of infinitely absorbing emotion (their own or others’) without issue, damage or complaint (5). In reality, however, clinicians are just as susceptible as anyone to a “significant range of normal responses” in the wake of challenging events (5). Numerous factors, from prior experiences to peer support, shape clinicians’ reactions to critical events, and, in turn, their capacities to resume professional and personal duties in the aftermath (1). But rarely is the emotional-constitutional diversity of medical providers considered; more commonly, the assumption holds that, “if an applicant can make it into medical school, then he/she is capable of dealing with life-threatening stress situations” (5,*).


With this mindset, the emotional roller coasters of medical practice will roll on. Dramatic experiences will come and go, punctuating the commonplace. And the potential for various manifestations of “distress and disruption” in physicians’ professional and personal lives—from hopelessness to burnout, bitterness to isolation—will continue to grow (1,6,**).

*Medical education in the United States has made significant strides in the areas of trainee/physician “wellness” and provider mental health over the past decade. Numerous residency programs have instituted opt-out, rather than opt-in, counseling services, for instance, and countless other initiatives have evolved to “destigmatize any negative emotions” (2). There is certainly room to grow, however, as the medical community works to actionably recognize “psychological first aid as CPR for the mental health crises in medicine" (2).


**Like most of us, doctors exist within families, communities, personal and social networks of various types. And, like most of us (to various degrees), they bring the weight of work and/or “outside life” back home to partners, children and friends. A common speculation is that “physicians’ personal relationships [often] suffer because of the demanding and consuming nature of their work” (7). A 2013 study found that, despite “overall satisfaction” with their relationships, spouses/partners of physicians may indeed report “substantial effect of the work life of their physician partners on their relationship” (7). From increased irritability to “emotional separation,” the psycho-behavioral manifestations of medicine’s emotional tolls can cascade to impact numerous individuals across life domains (8). This multiplication of effect may be even more significant in cases of physician post-traumatic stress disorder (PTSD, brought on by some critical event). Recent studies estimate that 5-30% of practicing physicians may meet criteria for PTSD (with variation across specialties and practice locations) (9,10).

Illustrative scenarios:

  • A physician partakes in a traumatic code that ultimately ends in a patient’s death. The physician goes home to play with his children at the end of the day.

  • A physician must see her next "well" patient just minutes after delivering news of a poor cancer prognosis to a longtime patient.

 

References

  1. Guidelines for Critical Incident Stress Management. American Association of Nurse Anesthesiology. https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/professional-practice-manual/guidelines-for-critical-incident-stress-management.pdf?sfvrsn=ba0049b1_6

  2. Paturel A. When physicians are traumatized. AAMC Medical Education. August 13, 2019.

  3. Wheeler DL. Emotional Extremes: a Day in the Life of a Neurosurgeon. The Chronicle of Higher Education. 1997.

  4. Leap E. Why are physicians burning out? Too many emotional extremes. KevinMD. December 28, 2012.

  5. Dyer KA. The Potential Impact of Codes on Team Members: Examining Medical Education Training. American Academy of Experts in Traumatic Stress. 2020. https://www.aaets.org/traumatic-stress-library/the-potential-impact-of-codes-on-team-members-examining-medical-education-training

  6. Meier DE, Back AL and Morrison S. The Inner Life of Physicians and Care of the Seriously Ill. JAMA. 2001;286(23):3007-3014.

  7. The Medical Marriage: A National Survey of the Spouses/Partners of US Physicians. Shanafelt TD, Boone SL, Dyrbye LN et al. Mayo Clin Proc. 2013;88(3):216-225.

  8. Your family feels the fallout of physician burnout too. AMA Physician Health. August 23, 2018. https://www.ama-assn.org/practice-management/physician-health/your-family-feels-fallout-physician-burnout-too

  9. DeLucia JA, Bitter C, Fitzgerald J et al. Prevalence of Post-Traumatic Stress Disorder in Emergency Physicians in the United States. West J Emerg Med. 2019;20(5):740-746.

  10. When a Child's Parent has PTSD. National Center for PTSD. U.S. Department of Veteran Affairs. https://www.ptsd.va.gov/family/effect_parent_ptsd.asp