The Matrix of Clinician Distress - Part 1

An Overview of the Psychological Phenomena Adversely Impacting Physician Wellbeing

Part 1 of a 7 Part Series

(What started out as a single article recapping a conversation with a journalist covering Covid frontline clinicians’ burnout quickly expanded into three, and then, as they were still in rough draft form when Part 1 was published, morphed into seven. As has become this blog’s style, I also produced them as podcasts, but as some found the articles longer than desirable for the audio format, I broke up some into multiple sub-podcasts. The entire Matrix of Clinician Distress series is available in article and podcast format - see footnote for more explanation on how to find.)¹

Recently, there’s been a lot of media reference to burnout. (If you’re a physician, you may even be burned out on the topic!) But in many pieces, the terms burnout, compassion fatigue, and moral injury are used interchangeably. Even further confusing is the mentioning of trauma and PTSD, grief, and the clinical mood syndromes of major depression and generalized anxiety disorder. And too often, these seem to imply that all such distress is a manifestation of mental illness, a fundamentally incorrect notion. 

Burnout, compassion fatigue, and moral injury are not interchangeable terms. They are distinctly different phenomena in the matrix of clinician distress.

It’s bound to be confusing for the general reader. However, the mixup is understandable as these phenomena often occur together leading people to believe that they’re just variable presentations of the same syndrome. They’re not, and this three-part article aims to clarify what each is, how they differ from one another and why knowing the distinction is key to helping clinicians resolve them.

For those of us who coach or treat physicians and nurses grappling with these syndromes, it’s critically important to distinguish amongst them. If you don’t recognize them as separate albeit often co-occurring entities, then your approach to helping resolve clinicians’ distress is going to be of limited success. One or another element of their distress is going to remain unnamed and unarticulated, or worse, mistreated. And left so, it will continue to do its damage and adversely impact the clinician’s wellbeing. 

Note: I’m using the term “clinician” here to group together all who are direct providers of healthcare, with a particular focus on physicians, mid-levels, and nurses. Of course, there’s a whole team of direct care providers such as respiratory and other medical therapists, social workers, psychotherapists, pastoral counselors, and many others. Please consider “clinician” as shorthand to include them all.

Part 1 offers an overview of the landscape of stress to which clinicians are subject. So that one can begin to appreciate their complexity, I start with a scenario many clinicians are familiar with and explain how clinicians actually experience the distress as it occurs and aggregates. The scenario encompasses a range of symptoms of psychological experiences that often occur together. Doing so will help set the stage to show the challenge - and importance - of teasing them apart. We’ll then more fully drill down on each of the syndromes in Parts 2 and 3. 

Part 2 delves into three of these psychological phenomena which, for convenience sake might be referred to as syndromes. Keep in mind, I’m writing this not as an academic paper in which one has to be precise in laying out exact criteria. Rather this essay is this physician coach/clinician’s practical translation of the experiential phenomenology and its psychological vernacular and the components of the discreet syndromes which occur in the universe of clinician psychological distress. It’s as much a desire to assist the distressed clinician and his/her coach or therapist as it is to help the general reader understand these often-confused phenomena. 

By convention, calling something a ‘syndrome’ generally implies ‘illness’ and therefore a medical malady calling for a diagnosis of some sort. Here, however, I want to use ‘syndrome’ in a looser way,  simply connoting a clustering of ’symptom’ manifestations that together comprise one’s understanding of that phenomenon. My reason for deviating from the conventional notion of syndrome and illness is that once we label something as a “diagnosis,” then we fall prey to medicalizing that phenomenon and thus, caught in that mindset, now having to initiate a medical “treatment.” 

Part 3 is devoted to the remaining syndromes of the Clinician Distress Matrix. I explore the remainder of the distress syndromes (grief, acute stress disorder, PTSD, and the affective syndromes of depression and anxiety) that are frequently mentioned in association with burnout, compassion fatigue, and moral injury and which also erroneously imply to the naive reader that they’re interchangeable. (I’ll strive to loop back here once published and insert links so you can read them as a series. But forgetfulness happens and should you not see the links, please feel to nudge me. To be sure you capture them all, just sign up for the Physician Interrupted newsletter on Substack and you’ll get notified as soon as the next piece comes out.   

An Era of Distress

We live in an age of issue overload and urgency. So many catastrophic events, so many demands. Abundant fears, whether about the stability of our jobs, the wellbeing of our families, the safety of our communities, or the world as a whole - it all weighs heavily on us.

People who do ‘people-work’ are at high risk of burnout.

The more urgent the risk, the higher degree of caring, the greater risk for your becoming burned out.

If you’re a professional in a field that is “people-work” oriented, and one where there are high stakes in the provision and outcome of those services such as in healthcare, you're at increased risk of burnout. You’re continuously under immense stress simply due to the high-intensity nature of the work involved in providing care. And, of course, you’re not exempt from all of the other stress bombardment that preoccupies us all.

Take that compounded stress and add in the challenge of dealing with an unparalleled life-threatening global epidemic caused by a lethal, highly transmissible, and self-mutating invisible pathogen, and in a setting largely unprepared for that lethal outbreak, the stress level goes off the charts. 

The Phenomenology of Clinician Distress

A Typical Scenario

This is a composite of experiences gathered from discussions with numerous clinicians.  While I myself experienced all of these (in spades!) in my clinician role more than a decade ago, and my distress symptoms concur with so many others’,  I did not have to contend with being a frontline physician providing care to patients suffering from Covid. That has added a whole new dimension of stress that is nearly inconceivable in its adverse psychological impact.

Your Experience of Danger

Today, as a clinician, you’re not just treating patients who happen to have a life-threatening illness, for example, a terminal cancer, and doing so as though you’re safely removed from their critical illness. Rather you are at extremely high risk of being infected by those patients’ rapidly progressive illnesses, and even more so than the non-clinician because of your ongoing daily exposure to continuous streams of newly infected and highly contagious people.

Your Personal Loss and Vicarious Loss

You may have lost close frontline colleagues to Covid. And you’re likely to have had to attend to patients who were gasping for air due to the severe pneumonitis and ventilator-resistant nature of the stricken lungs. It’s a powerful psychological trauma to witness a person die from an acute rapidly progressive disease, at that one causing severe air hunger and one that you cannot effectively treat with the limited means currently available. You don't just observe the air hunger clinically, you feel it; as humans, suffocation is one of our worst fears. You find yourself breathing with your patients as if to help in their respiratory effort. Early on, you may not have even had sufficient resources to protect yourself or to assist your desperately ill patients.

Empathic Stress

You face additional empathic stress as you are the one who maintains vigil, comforts them and, near the end of their medical survival battle, tries to arrange contact with their family member to allow a final visit, at that limited to a video conference with you holding the computer screen while your weakened, dying, short-of-breath patient and their loved ones say their heart-wrenching goodbyes.

Doing this caregiving work in these circumstances is so immensely stressful, it’s almost impossible to convey in words. And yet the psychosocial support services needed to help caregivers debrief and decompress, to compartmentalize and make sense of their experience, are largely absent. In fact, they’ve never been in place. And so you must contain your sadness and fear, your hurt and anger, and your sense of helplessness and failure in the face of a relentlessly aggressive and lethal infection caused by an invisible pathogen as light as air that continues to evolve into more malignant strains and threatens to immobilize all of humanity and cripple the very healthcare system itself. 

Your Moral Duty

As a frontline clinician, you may find yourself torn, believing on the one had that as you entered this world of healthcare after extensive training, it is your moral duty to remain on the frontlines and treat this flood of desperately in-need patients. Yet on the other hand, you wonder if indeed that is your moral duty or if you’re being too heroic about it, and that you also have a moral duty to protect and take care of yourself and your loved ones. With no place to process this, you remain torn and default to hunkering down. 

Trauma and PTSD

Even absent a pandemic, such intensive care work can be psychologically traumatic and leave one filled with sadness and worry, and brooding preoccupation. But in an epidemic where the stream of desperately sick people and the demands for 24/7 care by dwindling teams of highly trained caregivers is continuous, this psychological stress takes an immense toll. It’s virtually no different from being a warrior pinned down in combat with an unseen terrorist. The caregiver is a frontline combatant in a deadly war, fighting courageously with finite and rapidly dwindling resources.

Resilience Depletion

If you know anything about the experience of war and those who are called to fight them, you understand that even a well-trained stress-hardened warfighter can only take so much. War is like a boxing match, but with no referee in the ring and no limit to the number of rounds. In fact, there’s no end to any round and thus no opportunity for a mend-your-wounds break or for re-hydration, catching your breath, and a cooling drench.

In such a relentless war, it’s not difficult to imagine that no matter how strong or resilient you started out, with the stress intense enough and prolonged enough, 100% of participants will be beaten.

And that’s what we have in the present epidemic.

No End In Sight

For frontline clinicians, there’s no end. It’s a continuous state of emergency. Not only that, it’s one that shows signs of worsening and, like other deadly infections, evolving to overcome anything we can medically throw at it. And you have an ongoing worry that you yourself will succumb to the pandemic illness you’re relentlessly fighting, or that you’ll unknowingly carry the lethal strain of the infection home to those you love.

Resentment and Vicarious Regret

Because so many caregivers know the beneficial effects of the vaccine and the prophylactic mask, hand-washing, and social distancing protocols, it’s not difficult to understand why they might feel extremely miffed that patients continue to flood their hospitals who’ve not only not gotten vaccinated and not exercised well-validated prophylactic protocols but who have actively been defiant in their refusal. And now these people arrive in droves, having resisted vaccination and social prophylactic measures – not because of a medical contraindication or a rationally grounded reservation about the safety of the vaccine but because of commercially driven manipulated alarmism propelling opposition for the sake of opposition and worse, enrobing it with the star-and-striped fabric of patriotism. 

Duty to Treat?

It’s not difficult to imagine the unspoken internal dialog that a caregiver might have as we are now well into the second year of this very home-front war. It’s almost as if your patients had already been explicitly told not to play in a certain field because it was known to be dangerous and loaded with mines, and now they come in with their limbs blown off and in anguish and demand that you repair them. Or as if you’d been on duty as a lifeguard and had effortfully posted signs all along the beach that you can’t go into the ocean because of life-threatening rip tides and deadly undertows. And now entire crowds stream over the sand dunes, defying your warnings, and go for their swim simply because they insist they have a right to. And suddenly they’re all drowning, gasping for breath, screaming for your help, being pulled by the powerful undertow you warned them about. As a lifeguard, you might find yourself questioning "why should I put my life in danger to rescue these people when they chose to ignore my multiple warnings.” 

Alas, clinicians do not have the option of not treating someone. 

Compassion does not come easily. Nor for that matter does eagerness to give it your all once again. You feel hurt and angry and disregarded. You’re not especially heartened by their sudden come-to-Jesus “I should’ve gotten the shot” conversion.

War Weariness

So to understand this complex psychological stress phenomenon affecting caregivers, it’s important to recognize that there’s a profound war-weariness with its recurring psychological trauma, plus physical and psychological exhaustion. And underneath, an anger that those who could have done something to take care of themselves and those who lead them who could have encouraged them to do so didn’t. And now, they not only burden the already stress-maxed treaters and facilities, but newly expose them to an even more lethal variant of this mutating virus that would never have emerged had appropriate containment been achieved earlier through widespread vaccination, temporary sheltering in place, and easily enacted transmission-prevention protocols.

Face Shields, Heart Shields and Soul Shields: Self-Protective Detachment

As you yourself might experience, many caregiving clinicians feel exhausted and have had to emotionally detach and distance themselves from their patients’ plight simply to get through the day. They feel the enormous grief that accompanies the sense of helplessness in the face of an invisible pathogen wreaking havoc on their patients, a relentless physiological assault that their training neither prepared them for nor has any quick cure for. But dedicated and even with diminishing resilience, they keep showing up for their work of healing, seeing yet a newer stream of patients, this time around younger and thought to have been more resilient and illness-resistant. Alas, another failed hope in the face of a rapidly mutating virus. 

And despite their best intent to continue to care deeply and attend fully to every one of their patients, their capacity to provide fully in the ways they’re accustomed to doing is just not there. 

That giving, giving, giving can’t go on forever. Eventually something gives, and you stop giving.

Think of a time when you were running low on your emotional reserve, say you’ve got a colicky infant and a needy spouse and a demanding boss all doing their noxious thing at the same time, what do you do? The vast majority of us just try to cope, to navigate the competing needs while holding in our anger and hurt, putting aside our needs (a meal, water, a bathroom break…), and attend to the urgency of the moment. But as we all know, that takes a toll. That giving, giving, giving can’t go on forever. Eventually, something gives, and you stop giving. It’s not even voluntary. It just happens. It’s a form of unconscious emotional ecology in the service of psychological self-preservation.

The Moral Injury of Being Sucked Dry By An Indifferent, Demanding Systm

But you can’t get over that, no matter how much effort you put in to stay the course, it feels like your patients, your boss, or the higher-ups, or the whole system is sucking you dry, that they don’t care what you feel, that they just need you to get your patient care work done. And if you put up resistance or manifest irritability, you risk getting written up, labeled as having poor bedside manner, or not being a team player. And you’re really bent out of shape at the fact that the people you’ve devoted your professional life to caring for with hard-earned skill and compassion have become rude, demanding, argumentative. Not all of them, but enough to sour your day and make you feel like you’ve been betrayed, stabbed in the back by the very people you strove to work for and to help.

Encroaching Hopelessness

And you feel increasingly glum, alternately overcome with intense feelings of anger, worry, sadness, and hurt, other times numb to any feeling at all. You even feel guilty for feeling this way. You wonder if it’s worthwhile at all, this whole medical career. But meanwhile, you continue to plod ahead, doing your best to do your healthcare work but feeling like your body, heart and soul are beaten up and numb. And it overwhelms you when you sense that this doesn’t feel like it’s getting any better, that it will get worse, and that it could go on indefinitely.

Is This Burnout? Compassion Fatigue? Moral injury? 

In short, yes.

It’s got components of all three, and perhaps even more. If we expanded the differential diagnosis (the term used in medicine to propose several diagnostic hypotheses), we ought to include situational grief, trauma and PTSD, and the clinical mood syndromes of depression and anxiety. We’ll cover these in Part 3.

What’s crucially important here is to understand that for many clinicians, there’s a confluence of psychological phenomena all going on concurrently. There’s not one syndrome that encompasses all of these. It's a chaotic stress mix of multiple components and a physiological and psychological cascade producing intense feelings cumulatively eroding the clinician’s resilience. 

But, given our training and our desire to wrap in as many symptoms into a definable, nameable syndrome, the diagnostician, be they therapist or coach, tends to want to give it all a single label, e.g. "burnout" or “depression” or “moral injury.” And I would caution that doing so will limit the success of their well-intentioned remedial efforts, delay optimal treatment or enable mistreatment, and perhaps even doom them to failure. 

In Part 2, we’ll examine the first three syndromes of the clinician distress matrix – burnout, compassion fatigue and moral injury.

I welcome your comments and sharing.

(Part 2 is here.)

1. When you click at the very top of the page on the Physician Interrupted title, it’ll take you to Physician Interrupted’s table of contents page which lists all the articles and podcasts published. When you go to the archive page, you can sort them in a variety of ways. As some of the articles were longish, I broke up the corresponding podcasts into more manageable parts, e.g. 6A, 6B etc.

The articles’ titles aren’t exactly descriptive - I’ve put the topic covered in the subtitle which, space permitting, may or may not show up in the TOC. As I learn this medium, I’m sure I’ll find a better way.

The podcasts are all identifiable as they have a headphones icon. There is also a tab in the top header bar that takes you to just the podcast list.

The content of the podcasts is mostly the same as the article. While I read aloud the content of the corresponding article, to avoid the tendency toward sing-songy recitation and to give the feel of more one-to-one conversation, occasionally I’ve improv’d a bit. Nothing substantial. Some people prefer the written word; others enjoy a podcast; still others like having both. Some of the podcasts have some cover art; some don’t. I deeply appreciate your reading/listening and your patience as I’m still getting the hang of this. I’ll likely go back and prettify things at some point. But as they say “Perfect is the enemy of good (enough).”