Dr. Jillian Horton is a general internist, writer and medical educator based in Winnipeg. Her memoir about medical education, burnout and mindfulness, We are All Perfectly Fine, will be published by HarperCollins Canada in February, 2021.
“Why do you wash your hands so much?” a colleague once asked me while I was doing my rounds, noticing my fourth squirt of hand sanitizer in as many minutes. “You didn’t even touch anything in that room.”
It was a simple question, with a complex answer. In 2003, when I was a senior resident in general internal medicine at the University of Toronto, SARS hit our city with a vengeance. For months, we were enveloped in sweaty gowns, rigid face shields, damp masks and uncertainty. By the time the crisis abated, hundreds had been sickened and 44 people, including three health care workers, had died.
Obsessive hand-washing is one of the many traces those months left on my psyche. But despite how frightening it was to work on the front lines of a highly infectious and frequently fatal new disease, I don’t think of myself as terribly scarred from that time – perhaps because becoming a doctor scarred me in so many other ways.
Medical school and residency are physically gruelling and, to some extent, emotionally disfiguring. Data released in 2019 by the Canadian Medical Association reported that one in three Canadian physicians were experiencing burnout, and more than one in three screened positive for depression. Alarmingly, in the prior 12 months, almost one in 10 had experienced suicidal ideation. Other surveys have shown that depression in medical residents occurs at a rate that is almost three times that of the general the population, and despite the challenges in gathering the data, it is generally accepted in medical circles that doctors have a very high rate of suicide among white-collar professionals, and roughly twice that of the general population. But the evidence does not suggest that we are admitting people to medical school with a higher-than-average burden of mental-health problems; instead, the opposite is true. A 2014 study showed that medical students begin training with similar or better mental health than age-matched controls. In other words, we generally start out healthy, but something poisons us in the process.
I think of myself as a fairly typical case. l was a formidable student: tough, joyful, committed to patients and, having grown up with a profoundly disabled sibling, full of a sense of purpose. I was the gold medalist at my undergraduate university, then valedictorian of my class at a highly regarded medical school. I was considered to be an exemplary resident in virtually every respect. But I soon found myself staring down the barrel of a culture that demanded I put work ahead of physiological needs such as rest, food, or the expression of core emotions. Operating in a fog of chronic and severe sleep impairment, I sometimes made mistakes. Patients died, often graphically, in ways I couldn’t seem to forget. I wrestled with guilt and shame at my perceived failures, seeing them all as personal flaws. Nothing in my training prepared me for the emotional challenges I would face; the generations before me weren’t prepared, either. So I did the same thing those other generations had done: I stuffed it all aside, repressed the worst parts and kept it to myself.
Years later, people who knew me as a happy-go-lucky trainee are often shocked when I talk about how I struggled through it all. The truth is that it has taken me a significant portion of my adult life to undo the dysfunctional behaviours I turned to during those critical, formative years. Why? Because the culture that surrounds medicine creates and perpetuates the conditions for mental illness and struggling behind a brave face, exacerbated by real fears around medical licensing and confidentiality. And this is particularly bad news when it comes to considering the damage that will be done by the COVID-19 crisis.
We are constantly talking about curves and waves in this pandemic, but there will be ones for physicians as well: When the onslaught of patients is finally over, we will have our second wave. Our doctors, like all front-line health care workers, will find their adrenaline has run out. No longer in fight-or-flight mode, they will be confronted by the enormity of what they experienced, suddenly given time to reflect on what they could or could not do for the sick and dying, and a misplaced sense of guilt at their inability to help everyone. They will also have to contend with the feelings of helplessness associated with having to work with inadequate personal protective equipment, and no small measure of anger at a public that, at least in the early days of the pandemic, ignored life-saving recommendations to practise physical distancing, thus increasing the burden on the system and putting physicians and other health care workers directly in harm’s way.
My brothers and sisters in medicine will rise to this occasion; we will do the best possible job of managing the front end of this. But the data clearly show that many of us were already struggling before this crisis. After SARS, there was very little discussion around the mental-health impact of working through that experience, and in many respects, SARS was a tea party compared with what some of us are going through now.
So while we all look forward to what comes after COVID-19, I worry about what looms. I worry about the potential for post-traumatic stress disorder, for a flood of early retirements and even for a spate of deaths by suicide. I worry because I know how much we suffer even in normal times. Maybe this will split it all open and get it into the light. But as the numbers crest, no matter how bad it gets, what I am most worried about is the second wave. I worry that when it is over, the public that was so keen to beat their pots and pans for us every night will wash its hands of wanting to know how wounded their heroes are. I worry there will only be silence.
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