NEWSLETTER

Is There a Relationship Between Physician Burnout and PTSD?

In 2015, I was preparing dinner and listening to an interview with Bessel van der Kolk, MD--a psychiatrist who has contributed substantially to the understanding and treatment of Post Traumatic Stress Disorder (PTSD)--when I heard something that stopped me in my tracks. I turned off the stove burner and sat down at my computer to replay this segment of the interview several times because I was hearing something that ignited associations and suggested an hypothesis that tied together ideas I had been circling around for many years and intensely for two.

• How could we make things better in the practice of medicine--for me, the culture of surgery and hospitals? 

• How could we understand more intelligently why we start as medical students with such hope and aspiration and so many of us end up bitter, disillusioned or just plain disagreeable and disheartened? 

• How did we become so fixated on money as the critical source of our gratification? 

I knew that to make things better, we really had to understand what was wrong: we needed a diagnosis. But in a medical culture that suppresses physician suffering and historically rationalized our bad behavior as an expected if unfortunate manifestation of stress, it was pretty hard to get a hold of. Denial abounds. Even worse, my decision to pay attention and try to figure this out often resulted in being told I was merely projecting my personal problem. Given that I had focused my entire life on becoming a doctor and practicing surgery and was presently reckoning with consequences of that choice, I had to agree: this was an intensely personal problem, and gradually I got better at adding, “It also happens to be a personal problem shared by the majority of physicians.” 

The working diagnoses circulating among the newly proclaimed physician remediation specialists were weak and internally inconsistent. Little mention was made of early data that showed that it was often the most conscientious, “best” doctors who were referred for anger management and “retreading.” Behavior that was characterized as a failure of caring was actually afflicting doctors who perhaps cared too much, or at least more than average. If disruptive physicians all had personality disorders, how come they were so hopeful at the start? And what was happening with medical students? Almost half of second year medical students had signs and symptoms of burnout without ever being on the wards or exposed to the so-called Hidden Curriculum. I also knew that by concentrating on individual doctors, we were missing contributing features of the practice environment and the acculturation of training. This was more than unfair; it was a recipe for failure.

In the On Being interview with Krista Tippett, Dr. van der Kolk described a troubling circularity of the characteristic features of PTSD that in themselves present obstacles to treatment and put people at risk for recurrent traumatic experiences. What I noticed was that these features eerily parallel many of the habits we intentionally cultivate during the intensifying cascade of premedical then medical education and residency. 

These features discussed in the interview and presented in greater depth in his book, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, include loss of interoception, social isolation or withdrawal, and sleep disruption among others.

Dr. van der Kolk identifies two ways that PTSD predisposes people to subsequent trauma. First is that the internal disconnect from feeling and sensation deprives people of the warning signals that would otherwise lead us to withdraw from threatening situations. Also, there is a tendency for people with PTSD, especially when there has been sustained trauma, to be attracted to traumatic situations because they are familiar, dangerous perhaps but also familiar. We have a competing predilection for the known.

So many questions came to mind. Is it possible that many of us who find our way to a career in medicine are drawn to the intensity and high-stakes environment of medicine for the same reasons? Familiarity with trauma and distress? An effort to master our own or our inherited traumas? Do some of us find it easier to make the grade and adapt because we have trauma in our backgrounds? Dr. Gabor Mate in his recently screened film The Wisdom of Trauma notes the ruptured attachment that occurred when he was separated in infancy from his mother for a time during the holocaust, wryly reflecting on his drive as a physician, “If I wasn’t wanted, at least now I am needed.” Could our work addiction and specialty choices be influenced by these themes? I recalled the opening line of my surgery residency application essay, “Having been raised in calamitous circumstances, I learned early to manage crises.” This was true, but what I also have learned from Dr. van der Kolk and work by psychologist Rachel Yehuda is that even intergenerational trauma or trauma during pregnancy can render us more vulnerable to PTSD or complicated stress later on.  

What emerged most glaringly for me was the distinct possibility that, whether we start our physician journey with a history of trauma or not, the accommodations we learn to make to succeed in medicine would seem to precondition us for complicated stress down the road. It’s almost as if we rehearse the PTSD state, like a self-induced trance. Is there a relationship between PTSD and burnout? Are they on a continuum? Are we in fact confusing them?

The second thing that struck me was the shared quality between features of PTSD and medical training of separation from self. This can look like lack of compassion--the aspect of detachment, of not caring, but it is, I suspect, more accurately being cut off from oneself, a kind of persistent suppression of need, want, and sensation. This process is already well underway by the second year of medical school, and it started to make sense to me why medical students who haven’t been exposed to suffering patients or burnt out clinicians become detached, emotionally exhausted, and have a loss of a sense of purpose.

These are theories, but they have this telltale property of “reducing to unity” as explanations for complicated observations. They also begin to map new terrain, a way of learning to be a doctor that keeps us connected, intact, coherent. It explains why yoga and contemplative practices that deepen our felt sense can help rebuild and sustain our integrity and offer alternatives for maintaining presence of mind during critical events without resorting to emotional distance. These powerful practices and insights are the kinds of things I realized constitute the Missing Curriculum™. The Hidden Curriculum is just our assortment of maladaptive strategies that develop in the vacuum of the Missing Curriculum. The Missing Curriculum is part of the medicine doctors need to be the doctors Medicine needs. These encompass the intimate details of doctoring that are extraneous and virtually invisible to organized healthcare, that require independent nurturing in a physician-centered hothouse, which is the purpose of Metamorphosis Medicine.