Medical Examiner

The Mental Health Ramifications We Expected for Doctors Are Here Now

The baseline for getting physicians the care they need was low, even before the pandemic, our ER doctor writes.

A medical staff member in full-body protective gear walks past a flower tribute on the ground outside the hospital doors
A flower tribute to the late ophthalmologist Li Wenliang outside the Houhu branch of Wuhan Central Hospital in Wuhan, China, on Feb. 7. Photo illustration by Slate. Photos by STR/AFP via Getty Images.

Two emergency physicians, based at two different hospitals in the New York metropolitan area, are logging their days for Slate. At the end of each shift, they write a response to three questions: What was today like? How did it compare with yesterday? And how do you feel? We have offered them anonymity so that they can write freely about their experiences. Dr. Kelly Keene and Dr. Lauren Serino are pseudonyms. Read Week 1 here, Week 2 hereWeek 3 here, and Week 4 here.

Dr. Serino, April 23

“I think I’m having a panic attack,” says my friend Mark on the phone. He’s never had one before. “My heart’s racing and I can’t make it stop.” I ask him to put on the pulse oximeter I convinced him to buy when he first became sick with COVID six weeks ago. “It’s 160,” he says.

I tell him to send me a video. My first impulse is to be skeptical of the reading, because I prefer that to it being true. A heart rate of 160 is dangerous territory, indicative of arrhythmias, blood clots, sepsis, something. But maybe a sensor needs to be wiped quickly with a cloth. Maybe it’s not on his finger all the way! I continue mentally insulting his intelligence since that’s the safest explanation.

I get the video. It’s 120–160 beats per minute bouncing back and forth. He’s not short of breath. He’s not coughing. There’s no fever. Because of the way the rate is changing rapidly, I think about a-fib, which can cause strokes.

“You’re going to need to go to the hospital,” I tell him when his tachycardia doesn’t resolve.

There’s a now-familiar pause. I recognize it when I talk to any patient, whether I know them or not.

Fear. Fear has become endemic during COVID season.

It’s not just of the virus. Everything has a patina of fear. Lately I find that I can’t stop watching the clips on YouTube of protesters demanding the economy reopen. Red-faced, screaming. I don’t really hear what they’re saying, but I see it: fear. Fear of economic collapse, fear of change, fear of uncertainty.

I feel uncertainty too—we all do. Even if my reaction and my responses are entirely different than the ones I can’t look away from on the screen.

Fear is just uncertainty that’s come looking for a target. There’s still so little we know about how the virus behaves, who has it, who doesn’t, what the future will bring. Uncertainty is uncomfortable. I meditate, and one of the hardest parts for me is sitting with a feeling of discomfort. Sometimes it’s hard to discern if a feeling is emotional or physical, though the longer I sit with it, the distinction frequently becomes beside the point. A vague sense of unease that can’t be pinned down is anxiety-provoking. We want to know where the fear is coming from, and so we point fingers. The stay-at-home orders are the target for some, like those protesters online, sure of a hierarchy of freedom, convinced that normalcy will ward off death. For others, the fear centers on their health and that of their families. But as time has gone on, fear seems to have become diffuse. You can recognize it in everything. But nothing is so broadly representative of our fears as the hospital itself.

It’s the isolation from family and the lack of visitors. The visual and written representations of all those individuals who were brought in and never came out, whose bodies were never seen one last time, whose families didn’t get that last look to convince themselves of their loved one’s mortality. The hospital is the synecdoche of the entire COVID crisis.

This is why my patients are calling into telehealth for problems that are too complex to solve anywhere except an emergency room or acute care setting. But as I spoke to my friend—whose heart rate finally did improve and who agreed to be seen in the clinic the next day—I realized that the fear has become so ingrained that even people with COVID are afraid to go to the hospital.

I can almost hear the magical thinking: If I don’t go in there, I’ll be fine. As if the act of entering the hospital is the leading cause of mortality, not the symptoms that required a visit in the first place.

I can almost hear it, because it plays in my head too. It’s a dangerous voice. As overall mortality in heavily affected cities rises compared with similar months in prior years, it’s proven to be a voice that kills. It’s important to heed warnings: wear masks, physically distance, wash hands, don’t come to the ER unless it’s an emergency. The problem is understanding what qualifies as an emergency right now. Because if it is? Please come. Please don’t wait until your appendix bursts, or let your stroke go untreated, or allow your COVID-related symptoms to threaten your life when we could support you.

And when you do come in, tell us you’re afraid. We are too. We will get through this together.

Dr. Serino, April 25

This week, a nurse at Kings County—mythologic in her presence there for the last 30 years—died. So did a much-loved ICU doctor, also at Kings. At a few other hospitals around the city, more health care workers have passed away, and one medicine attending—who has always been such a pleasure to work with—is on ECMO, and I can’t imagine he’s going to make it. All of these deaths were caused by COVID-19.

Tonight, a friend and colleague told me that an ER doctor in the city, whom he has known since residency days, died by suicide. A 24-year-old EMT did as well. Their deaths were caused by COVID-19 too.

I’m thinking back to something I wrote in the first week of these logs. “We’ll lose colleagues to this virus. Both to illness and possibly to moral injury later. I worry about everyone’s mental health.”

We’ve already gotten to “later.” Later is now.

There has been some speculation among psychiatrists I work with as to the possibility of a physiologic, neuropsychiatric effect caused by COVID-19. After all, the loss of sense of taste and smell in many patients suggests that the virus can target the nervous system. There have been case reports of encephalitis, an inflammatory condition of the brain, and other cognitive-behavioral effects. It would follow that perhaps depression, psychosis, or suicidality could also be caused by infection.

Information from the general population will have to be the source of the data that helps us see if this is the case. Because we’ll never find out if we rely on physicians who have had COVID-19 to self-report. We may experience it, feel it, fear it. But we won’t say it. The culture of medicine demands machismo.

Here’s a story: Once, I worked an entire shift attached to an IV pole with fluids and Zofran. I’d been ill for days, but if I’d called out, I would have been responsible for finding my own replacement, owing them favors, and being branded as lacking work ethic. There’s a saying among physicians: Either you’re taking care of patients, or you are a patient. If you’re not requiring hospitalization and you claim you’re unable to work, you’re weak. And weakness? Among physicians, that’s considered more virulent than any biological infection.

We’ve all known colleagues who worked until their water broke, and then still finished their day because the contractions seemed far enough apart. Physicians who found out their parent died and then showed up an hour later to start a 12-hour night shift. We all know these stories, because we tell them ourselves in a kind of one-upmanship of commitment. This kind of pride must be the result of a sort of medical Stockholm syndrome. Because if you stop to consider how ridiculous it is to be proud of putting yourself and your patients at risk, you have to admit that you do it because it’s expected of you, and you must do it no matter how you feel about it or risk your reputation. Better, at least in feeling, to see this behavior as a badge of pride instead of a way your field subjects you to systemic abuse.

The suicide rate for male physicians is 1.41 times higher than the general male population. For female physicians, the rate is 2.27 times higher than the general female population. It’s the second-leading cause of death for medical students.

Trauma creeps in. Health care providers—from EMTs to nurses to physicians, anyone, really, who is part of the patient care team—see things that have been sterilized from modern life. The first time a patient dies under our care, the first traumatic arrest, the first young person we lose. We acknowledge the early impact. But as we accumulate suffering and loss, it becomes normalized. We become desensitized. Or we say we do, but the longer I practice, the less I become convinced.

Just because we’ve trained ourselves to pronounce the time of death of a 6-year-old who bled out in the trauma bay secondary to a gunshot and then, less than five minutes later, be at the bedside of a man with an infected kidney stone (without a hint on our faces to give away what we just saw even if there’s still a spot of blood, belonging to that boy, on our sneakers), doesn’t mean that healthy processing has taken place. Compartmentalization may be required for us to do our jobs well, and should be a skill we all have—you shouldn’t give one patient substandard attention and care because of a real-time emotional response to another—but the experience doesn’t just disappear because we will it to or, more frequently, just don’t have time for it.

We’ve all seen things that can’t be forgotten. We all have the names and faces of those human beings we met and lost within the span of hours, or minutes, lodged deeply in our hippocampus. That detachment we cultivate is what keeps us going. But that doesn’t make it adequate coping. And it doesn’t mean that one day, those hardy memories won’t overtake the landscape, leeching the color from our well-tended gardens.

So when we wonder—is there something about COVID that affects decision-making? could it have a psychiatric effect?—there’s another, more insidious component to consider. Have we made it so socially, culturally, and bureaucratically punitive for a physician to come forward with a mental health concern—even one that is in reaction to a once-in-a-lifetime pandemic, the personal stress of which is widely acknowledged—that most are too afraid of the downstream effects to seek help?

When doctors find themselves in a position of psychiatric distress, the decision to seek help comes with another choice—between the job they’ve worked their entire lives for, and their lives. At some point, let me assure you, these two things feel like one and the same. Whether you’re seeking care for a diagnosis or looking for counseling to work through a devastating patient experience or lawsuit, the mere act of seeking that care is asked about when applying for jobs and licenses. Fear of checking “yes” to the question of seeking mental health care on these applications leads to delays in or complete avoidance of asking for help. If it is done, it is often with great fear and avoidance of using insurance or traceable payment options, forcing the already fraught act of admitting to the need for help into the realm of feeling shameful.

The question often used to justify the punitive nature of disclosure is: What if physicians’ mental health concerns lead them to be incapable of providing adequate care? What if it puts patients at risk?

But that’s the wrong question. Because what if a doctor not getting care puts a patient at risk? What if a doctor not getting care puts the doctor at risk? If we feel that getting even basic mental health support may mark a physician as unfit for patient care, what does that do to underscore the stigma already surrounding mental health care? If the very things that make us human, that cause deep hurts, are turned against us when we acknowledge our humanity and ask for help, what else can we do but avoid the support and convince ourselves that our position as physicians somehow makes us less at risk? The right question should be this: How can we acknowledge the stress and trauma inherent in being present for so much death and suffering and improve support? If there is real concern over the mental health of doctors in regard to patient outcomes, it behooves us not to punish those suffering, but to broadly prevent sequelae from untreated illness or trauma.

Psychiatrists have it right. They frequently require or offer therapy and group support for their trainees so that they can better understand the patient’s process, but also so they can work through their own experiences and learn to discern between their and their patient’s burdens. It baffles me that we don’t require and normalize counseling in other fields. So many of us have developed our own, mostly successful coping mechanisms. But so many of us haven’t.

For me, I write about the things I see. I have always written about the things I see. Often, I don’t know what I think until I write what I think. I don’t know what I feel until I write what I feel. And in doing so, I discover the veneer of detachment is blocking the way to a number of often difficult and complicated thoughts. It keeps me honest with myself. It keeps me connected. Stories are a place for my dead to rest. Even there, they have a way of becoming restless.

Tonight, I write about our lost colleagues. I do it to remember them, not forget. But what I really want is to know how we can prevent the loss of more. And I’m worried that writing is not enough for that.

Dr. Serino, April 26

I went for COVID antibody testing today. It’s human nature to want to know. I’m not above it. The problem is there’s one thing that I already do know: I won’t trust the results. With some tests having a sensitivity as low as 80 percent, and a specificity in the range of 90–98 percent (values whose influence on the interpretation of results changes with the prevalence of the disease, which is, of course, something we need to determine with the help of testing), each positive or negative result comes with the chance of being wrong.

If my results return positive, it may mean that I have a false positive, or that maybe it’s just picking up on another, different coronavirus infection from my past, maybe the cause of a seasonal cold. If my results return negative, it may be a false negative. I may have been infected but was tested before my body had the time to produce enough antibodies to quantify, or I may have been infected but not produced a meaningful antibody response. So if I’m positive, I may or may not have had it. And if I’m negative, I may or may not have had it. Without an associated nasal swab, it’s hard to say.

And yet I’m still getting the test, because even if it won’t change anything about how I live my life, it’s a data point. And the more data points we have to correlate with nasal swabs and reported symptoms and large population studies, the better we can interpret results. Obviously I’m hoping that I have magic antibodies, brimming to overflow, proof of a silent and now complete bout of the coronavirus. I get that this is silly. I understand that we don’t even know if or for how long antibodies confer immunity. Still, I want them.

There’s been such a lack of certainty in regard to the coronavirus. This is normal—there’s a lack of certainty in regard to anything novel. But it’s also normal that we still want our experts to be able to tell us something as simple as the “classic” presentation of the illness, or to provide a test that can tell us with some level of certainty if we have it or not. I want this, even as the expert sometimes is me. Our ability to model the future in the face of COVID depends on our ability to answer the question of who is infected and what antibodies mean practically. Is herd immunity possible? How long does immunity last? Can the presence of antibodies be the passport to returning to a “normal” life? I know from my days in med school that there’s a good chance they’ll do something, and that it will be something protective. But it’s not a given. And changing our behaviors too soon may lead to unnecessary risks. Until we know more, we’ll have to bide our time.

There’s one other thought I’ve been having too: Antibodies may be a powerful asset in my search for work, which has continued to be a series of dead ends locally, which will likely continue to be the case until the next wave hits and the job market improves. Including antibody status in a cover letter may be helpful if it turns out antibodies confer some level of immunity. A prior illness would suggest you’d be unlikely to call out sick or complain about PPE. This week, even as co-workers die of the disease, many more are having their hours cut significantly; retroactive pay cuts have been established; some of my graduating residents have had their first job offers rescinded; and recruiters, who were previously aggressive in their tactics to hire, are not returning calls. One who did said that they heard hospitals were focusing on a nurse practitioner–led ER-staffing model, so they were holding off on physician hires for now. What that means is that doctors and their tens of thousands of hours of training and expertise may be in the ranks of “heroes,” but hospitals may soon prefer to provide the bulk of a patient’s emergency care from a different kind of health care worker. Nonphysician health care workers like nurse practitioners and physician assistants play an important team role, but they do not have to complete a three- to four-year residency in the specialty of emergency medicine after completing medical school.

So, while I wait for my results, I’m hopeful that my data point (mixed with thousands of other data points in this study that involves the sampling of asymptomatic, high-risk-of-exposure individuals) will lead to information that points us forward. If I appear to have antibodies, I’ll be able to get tested a second time and, if positive, donate plasma to critically ill patients in New York. That way, I can be put to work against COVID even when I’m not in the hospital on shift. Helping to heal people while asleep in my own bed? That’s what doctors dream of.