“There’s a surge in calls. We need more backup,” read the text I got last week from my colleague Mona Masood, a psychiatrist and co-founder of the Physician Support Line, a peer-to-peer hotline that she, I, and others developed in response to the Covid-19 pandemic.
With 700 volunteer psychiatrists staffing the hotline, my first thought was, “How is that possible?”
My second thought was “Ah, yes. We are still demoralized.”
Back in March, I watched from the front row as the pandemic overwhelmed health care workers with moral injuries — acts that conflicted with our values. We felt betrayed by government messaging that flew in the face of science; powerless when administrators restricted protective equipment; apprehensive when treating patients who might expose us — and subsequently our loved ones — to Covid-19; and incompetent in our ability to cope with this new disease without clinical guidance. Attending physicians became interns again as we scrambled to understand the novel SARS-CoV-2 virus.
These moral injuries don’t necessarily have long-term consequences. They can spark growth, insight, and redefined life purpose. But during this year of constant unrest and disorientation that underlies our everyday routine, clinicians are left with a collective demoralization.
Introduced by psychiatrist Jerome Frank in in 1961, demoralization is defined as a persistent, subjective inability to cope in the face of overwhelming situations. Rattled to the core by existential distress, one’s usual beliefs and convictions give way to uncertainty, frustration, and restlessness. Trust in humanity dissolves, leaving a sense of futility in its wake.
Ten months into the pandemic, we know more about the virology and clinical management of Covid-19. The president-elect has prioritized science, public health, and effective management of the pandemic, giving doctors and other health care workers a second wind.
But a window of opportunity seems to have closed, shut in part by the public’s fatigue and burnout from the pandemic. Cognitive dissonance settles in: The public knows there is a risk of infecting loved ones, yet they want to — need to — justify their choice to not follow public health precautions as they minimize the odds of contracting or spreading Covid-19.
This likely contributes to why there are more people hospitalized with Covid-19 than ever before. While the lack of protective equipment seemed the rate limiting factor during the spring, this winter it will be a lack of health care professionals to manage the overwhelming number of patients as medical practices close or clinicians become infected. The supply chain for clinicians isn’t as easy to fix as the one for PPE.
Health care workers are losing compassion for the general public.
As a psychiatrist, I must care for my patients in order to engage with them and not avoid their emotional turmoil. I must rein in any apathy I feel so I can do my job: to listen for meaning, validate, and avoid judgment. But that is hard when there are indoor weddings and soccer tournaments with 500 teams occurring as Covid-19 once again surges across the U.S.
I’m tired of this pandemic. Fatigued from trying to decipher my patients’ tears through screens. Burned out from witnessing how much of life is going un-lived: deferred playdates, empty college dorms, canceled family reunions, parents and grandparents alone on holidays. And stressed from working a full-time job and homeschooling my two kids under 5.
But it isn’t just the constancy of Covid-19 that causes distress. It’s also the breakdown of social values that weighs me down.
I spoke with a colleague of mine, James Griffith, chair of psychiatry at George Washington University, who designed a curriculum to combat demoralization. He told me how pervasive demoralization is and yet how widely ignored it is as a concept in our society.
“Demoralization is not in itself a mental illness but rather a normal human response to circumstances perceived as overwhelming,” Griffith said. “We lose our sense of meaning.”
For me, meaning comes from my roles — as a mother, wife, doctor, teacher, daughter, friend. But all these identities need me at the same time and, in 2020, at a magnitude I’m not sure I can manage. Medical school mistakenly taught me that the concerns of patients always supersede my own. With so much of my psychic energy diffused, I am losing the ability to give. And I know I’m not alone.
Consider how many continued, unresolved problems we are facing that feel morally wrong: Seniors isolated in their last years of life. Children wrenched from their formative places of education. Countless victims caught in the structural violence of inequality, most of them people of color.
The ongoing pandemic has revealed the ugly exploitation in our society: of health care workers, teachers, bus drivers, grocery store and factory workers, and others who are often forced to work in unprotected, high-risk situations.
At the crux of demoralization is despair over moral injustices and subjective incompetence — the belief that we aren’t coping as we should be. We know we need better sleep and more exercise, but the moral injury of seeing patients dying without loved ones present depletes the energy that would have been used for a run. There are no good options to reconcile the social acceptance of racism or the lack of feasible options for child care or education.
Hope can be an antidote to demoralization, and the incoming Biden administration and vaccine developments provide that. But the president-elect is also inheriting a health care system and a society that are on their last reserves from this pandemic, and it will take another season or two before vaccines become widely available.
We can’t ask any more of our health care workers. As Mona Masood told me, “Physicians are holding up a sinking boat, but they themselves are drowning.”
Physicians do not learn how to set boundaries in medical training. To the contrary: I — like many others — delayed dating, financial planning, and having a child all to care for patients. We are taught to be the last resort for those in dire need. It’s therefore no surprise that physicians have higher rates of suicide than the general population.
Physicians take a Hippocratic oath to “do no harm.” It’s time that oath includes doing no harm to ourselves.
I will continue to serve as a backup for colleagues who turn to our hotline for help, and will strengthen personal boundaries. But support lines, meditation, and walks only go so far.
For the many Americans who are taking appropriate precautions against Covid-19, thank you. It feels like we lack control over so much of our lives now. But we can do our part to be a society that values caring for each other enough to take personal responsibility: wear a mask, avoid gatherings, and wash hands.
We may desperately await a vaccine now, but soon we may instead be hoping for enough physicians to care for us.
Suzan Song is a psychiatrist and director of the Division of Child/Adolescent & Family Psychiatry at George Washington University. She is also an associate with the MHPSS Collaborative/Save the Children and a co-founder of the Physician Support Line, which can be reached at 888-409-0141.