But the headline was grim: “Top E.R. Doctor Who Treated Virus Patients Dies by Suicide.” The article was about Lorna M. Breen, the medical director of the emergency department at New York-Presbyterian Allen Hospital, who died in April. Her father, also a physician, said Breen had contracted the coronavirus but had gone back to work, before traveling to Virginia to rest. Watching patients overwhelm her hospital — dying before they could even leave ambulances — took a toll, her father said. It was a sunny morning in New Orleans, light streaming into my home office where I read the piece at my desk, then read it again and again. For the next few days, in the quiet hours inside my house, where I was working — and with too much time to ruminate — I couldn’t stop thinking about her. I also thought: That could have been me.
I was a physician in a top academic center until I suffered a crisis that stopped well short of my wanting to kill myself, but it did upend my life and career, one that I had carefully planned and faithfully executed.
For more than a decade, until the summer of 2016, I led the lung transplant program at Stanford Medical Center. Our team did wonderful things, providing lifesaving transplants to extremely sick patients, restoring hundreds of dying patients to health — and back to their families. In return, the gratitude patients showed to me and my team was overwhelming, humbling and seductive.
But I also watched some of my patients die. Standing by helplessly, a piece of me went missing every time one of them passed away. As time went on, I couldn’t focus on the good outcomes, only the bad ones.
I went from being a confident, somewhat robotic transplant specialist at the top of his game to a defenseless, vulnerable midcareer physician who couldn’t bear to see suffering and death anymore. Every daughter was my daughter, every wife my wife, every mother my mother. And I needed to save them all, though it was obvious to everyone but me that I could not.
During my last couple of years at Stanford, it was only a matter of when, not if, my train would derail. I spent less time with my patients and colleagues; all I wanted was to go home, read a book or watch a game on TV. Insomnia? Check. Irritability? Check. I attributed my weight loss — at 5’10,” I was 137 pounds — to a passion for cycling, but today I realize that I was unconsciously trying to starve myself, to punish myself for whatever perceived sins I had committed.
Thinking now about what I put myself through, the words of William Osler — one of the original faculty members of Johns Hopkins Medical School — come to mind: “In no relationship is the physician more often derelict than in his duty to himself.” Still, my initial instinct was to scold myself. Get your act together, get tougher, get going. I kept hearing what my physician father often told me, quoting 19th century British prime minister Benjamin Disraeli: “Never complain; never explain.”
I managed to avoid some of the less-desirable coping mechanisms that have stricken some of my colleagues, such as alcohol and drug abuse. And I found a therapist accustomed to working with driven adrenaline addicts who had lost their sense of purpose. Doctors are often leery of therapy, seeing it as for the weak, worried about the judgment of their colleagues. But for me, it was liberating, allowing me to express thoughts that had never before come out of my mouth and in many instances, that I didn’t even know existed within me. I was using words like “vulnerability” and “limits,” “gratitude” and “acceptance.”
Though I understood myself better, I knew there was no going back. At what should have been the prime of my career, my stark choice was to take care of my patients or take care of me. I had to leave. Now, I advise transplant programs in a consulting role, more coach than quarterback, but I think about being on the front lines every day, the allure too strong to completely dismiss.
According to recent studies, more than half of physicians experience burnout, and doctors have twice the suicide rate of professionals in other professional fields. Burnout is so common — even before the pandemic — that perhaps the key question is not why some physicians burn out but rather why more do not.
Studies of burnout suggest it’s caused by an array of factors, from the loss of independence caused by the corporatization of medicine, to the drudgery of the electronic medical records, to petty hospital politics, to the dehumanizing way physicians have traditionally been trained. These explanations ring true, but I suspect some of our susceptibility has to do with physicians’ innate desire to control circumstances that simply are not controllable.
And now the pandemic is exacerbating physician burnout for a host of reasons, including concerns about infecting family members, the stress of working without school or day care, a continued lack of personal protective equipment and frustration about the botched national efforts to control the coronavirus. Early in the pandemic, British physicians proposed, in a medical journal, that the “moral injury” caused by providing health care under conditions of scarce or inadequate resources might be a particular contributor to burnout. “Moral injury” refers to the trauma of witnessing events that violate one’s ethical system. The authors explained that health-care constraints during this crisis sometimes make it impossible for doctors to say to the family of a deceased patient: “We did all we could.” Rather, all that can be said is: “We did our best with the staff and resources available, but it wasn’t enough.”
As coronavirus cases overload medical facilities in new hot spots, we will see the kind of health-care worker burnout nationally that we’ve already witnessed in, for example, New York and Italy. Although we don’t yet have complete data, reporting from the front lines and my own conversations with colleagues make it clear that burnout will be part of the collateral damage associated with the pandemic. One study, of 1,400 health-care workers in Italy, at the peak of its pandemic, found that half showed signs of post-traumatic stress disorder, a quarter experienced depression and 20 percent had anxiety. I knew what these doctors and nurses were going through; I had been on the front lines in the AIDS crisis, in the 1980s and 1990s, intubating patient after patient, sometimes ending a shift covered in an infected patient’s blood.
Despite the physical and mental hazards, I considered returning to the front lines to help fight the coronavirus. After all, I still had more than 25 years of ICU experience and certainly knew my way around patients with sick lungs. For weeks, I read up every day on covid-19, the disease caused by the coronavirus. But I ultimately realized that I could not go back into the fray. I had a more balanced, middle-aged life for which I was grateful, including a loving wife and two wonderful teenage daughters. When I worked in the hospital, I did my best work when I was my most selfish — with my time and with my emotions. I didn’t have that disposition any longer. I had lost my armor back in California and didn’t feel confident that I could get it back.
When I think back on my crisis, my main impression is just how isolated I had become. In fact, “physician isolation” might just be a different way to say “physician burnout.” Solitude — physical and spiritual — is the gasoline that fuels the burnout fire. The cure is connection — to people who understand the perils of our profession and who have the insight to take action if the situation becomes untenable. Today’s health-care workers need a supportive network that ranges from friends to clergy to mental health professionals. And they need to be willing to tap that network, without shame, so we don’t lose any more of our best people during this health emergency.