When emergency physician Lorna M. Breen took her own life this past April, it sent shockwaves through the medical community. Breen was a medical director at the prestigious New York Presbyterian-Allen Hospital, which was overwhelmed with patients in the early days of the U.S. coronavirus pandemic. Colleagues and family remembered her as an extremely talented and devoted doctor, who was deeply traumatized by the horror of the pandemic.

Breen’s case brought attention to the ongoing trauma faced by healthcare workers during a prolonged public health crisis. Studies already show high rates of PTSD in medical workers who have been braving the pandemic. In Italy, almost 50% of surveyed medical workers have demonstrated PTSD symptoms related to the pandemic. A full 70% of Chinese medical workers exhibited serious distress.

In the United States, where cases continue to surge and PPE and staffing shortages remain, many medical workers are showing signs of depression, panic, and paranoia. “This isn’t posttraumatic yet, because the trauma piece is still ongoing,” Laura S. Brown, a clinical psychologist, told the American Psychological Association.

While the pandemic is placing unprecedented strain on the American healthcare system, some medical workers say that these problems aren’t new. Just as the coronavirus has revealed the glaring gaps in the United State’s mental health and housing safety nets, it has also brought the challenging conditions medical workers face into sharp relief.

“The pandemic arrived to a healthcare system that’s already deeply in crisis,” said Wendy Dean, a psychiatrist and president of Moral Injury of Healthcare, a group that advocates for more sustainable medical workplaces. “All of the challenges that clinicians are facing prior to the pandemic are just highlighted, exacerbated, and added to.”

Medical Professionals Are Facing “Moral Injury”

Dean’s critique of the American healthcare system began long before the pandemic. She began her medical career as a surgeon, switched to emergency room medicine, and eventually settled on psychiatry. Some called Dean’s career “eclectic.” But she was simply searching for a specialty that would allow her to provide the best care for her patients.

“I was trying to find a way to take care of patients in the way I knew they needed to be taken care of, that was also sustainable for me,” Dean said.

But the profit-driven model of our medical system was coming in the way of that. Administrators urged doctors to schedule as many patients as possible, meaning they weren’t all getting the attention they needed. Meanwhile, the need to constantly tend to electronic medical records took away from face-to-face time with patients, and encouraged doctors to bring their work home.

Dean left practice after ten years. The more medical workers Dean talked to, the more she realized that she was far from the only one who felt deeply conflicted. Doctors she spoke to reported a tension between the care they wanted to give their patients, and the constraints of the system. “They were breaking a covenant to their patients,” she said.

There’s a word for this feeling: moral injury. The term refers to the intense dissonance people experience when a system compels us to do something out of line with our deepest-held values. Psychiatrist Jonathan Shay first coined the term in relation to the trauma faced by Vietnam veterans, many of whom were haunted by memories of times they committed atrocities at odds with their moral beliefs.

Dean defines moral injury as “perpetrating acts that transgress deeply held moral beliefs.” She said the trauma medical workers are experiencing during the pandemic isn’t just because of the sheer horror of the virus, though that’s traumatic, too. It’s also a form of moral injury, resulting from deep-seated problems that prevented the American healthcare system from responding appropriately to the virus.

COVID-19 Revealed Long-Term Problems

As the pandemic was approaching, many doctors asked hospitals to shut down elective procedures immediately, in order to conserve resources and stop the spread of the virus. But at some hospitals, there was hesitation: after all, elective procedures form the financial lifeblood of most American hospitals. When government mandates forced elective procedures to shut down, the loss of revenue meant layoffs even at a time when medical workers were urgently needed.

This profit-based model, said Dean, is one of the many ways in which the health care system was not adequately prepared for the pandemic — and one of the many factors leading to moral injury to health care workers.

Other barriers added to the harm. During the darkest days of March and April, when medical workers were treating patients with a dangerous lack of PPE, many tried to organize for greater protections. But some were met with reprisal, causing the physical injury of COVID-19 exposure to mingle with the moral injury of retaliation.

“We were telling our organizations what they needed, and weren’t being heard, or were being dismissed,” Dean said. “That’s a different type of trauma. That’s the trauma of betrayal.”

What’s more, even when medical workers want to seek psychological support for their experience, they are often hampered by restrictive licensing regulations that scrutinize all records of psychiatric care. Even if medical workers don’t have serious ongoing symptoms, licensing boards can require them to participate in restrictive and expensive inpatient programs in order to obtain licensing. This discourages medical professionals who wish to seek mental health support.

How Medical Workers Can Practice Self-Care

While Dean believes systemic change is needed to truly get at the root cause of moral injury, there are ways medical professionals can care for themselves during the pandemic. First, she said, it’s important to simply prioritize basic needs: food, water, shelter, PPE, the safety of professionals’ families, and adequate sleep.

This is easier said than done when supplies of protective equipment are short, and sleep, even shorter. But the American Medical Association advises some ways medical workers can still practice self-care. These include:

  • Feel your feelings. It’s not weak to acknowledge feeling overwhelmed, depressed, or exhausted. Feelings always have a way of making themselves known; ignoring them now means they will come back stronger later. Wendy Dean recommends using mindfulness as a way to continue to check in on what you are experiencing and what you need.
  • Employ coping strategies. Most medical professionals have a toolbox of coping strategies they’ve already employed to get through their laborious training and the daily strains of working in healthcare. Draw upon this toolbox now. Connect with family and friends remotely or in a socially distanced way, practice a hobby, or get out and enjoy a form of exercise you love.
  • Take a break from the news. Choose one or two reputable news sources and stick with them. You’re living the pandemic; you don’t need to know every pundit’s take on it.

Dean adds that it’s important for employers and support networks not to stigmatize or label medical workers for experiencing distress. “Recognize this as an expected reaction to an extraordinary event that most people will recover from just fine,” said Dean.

Finally, said Dean, we all need to accept that it will likely take a while for the full extent of the trauma to unfurl — and even longer to heal. She advises organizations to maintain needed mental health services for medical workers for up to three years.

Above All, Medical Workers Need Support

The trauma from the pandemic is profound, and collective, affecting not just medical workers and their families, but all of us. It will take time for society to witness the pandemic’s full effects. “It has changed people,” said Dean.

In the meantime, however, we can support medical workers by providing immediate care, and advocating for long-term mental health support and for a medical system that values patients and workers over profit. “As difficult as this pandemic has been, the silver lining is that it has shown everybody what the gaps and vulnerabilities in the healthcare system are,” said Dean.

And even though she’s spent her career examining the way that healthcare causes moral injury to its practitioners, Dean holds out hope in our collective resilience. “I am a determined optimist.”

Medically reviewed by: Ashley Ertel, LCSW, BCD

Reviewed On: September 16, 2020