In the “before times,” most Americans went about their lives relatively unpreoccupied with death. In fact, one CBS News poll found only 14 percent of Americans spent “a lot of time” thinking about their own mortality.

What a difference a pandemic makes. With every masked trip to the grocery store, every passerby who coughs too close and every “doom scroll” through a newsfeed, our brains register impending doom. More than any event in recent history, the coronavirus crisis has distorted our nation’s way of thinking and living.

But not everyone has been affected equally. In contrast to most Americans, doctors are well-trained and culturally conditioned to deal with the constant threat of death. It’s a skill that’s being used and put to the test like never before.

Mission: save a life at any cost 

Starting in medical school, doctors and death become familiar foes. From Anatomy 101 to residency, physicians spend countless hours learning what it takes to keep the human body alive.

That is always the goal: save a life at any cost. Only once you understand this goal do a doctor’s actions make any sense. When it’s your job to save a life, you eagerly slash open a throat to establish an airway. You crack open a chest to massage an idle heart.

To be a doctor, you must be comfortable repressing uncomfortable feelings. You must deny fear and doubt and pain and grief, and any other distressing emotion that might inhibit your ability to save the next life. These psychological coping mechanisms—repression and denial—are hardwired into doctors through decades of cultural immersion. These potent defenses are foundational and indispensable to the practice of medicine.

And yet, they have their limits. COVID-19 has breached those limits.

“I wake up before sunrise covered in sweat”

More than a year into the pandemic, the majority of frontline physicians say the COVID-19 crisis is taking a toll on their mental health. Those most affected are critical care and infectious disease doctors. Because they serve the dying, they’ve become two of the three most burned-out specialties, according to a recent survey of physicians.

To better understand their experience, I called three ICU doctors I know well. At their requests, I’ve omitted their names.

The first doctor, a resident, told me he’d been assigned a half-dozen COVID-19 patients on the first day of his ICU rotation. “They were all dead by the end of the month,” he said. Before the pandemic, ICU residents like him could expect nearly all their patients to go home alive.

Next, I phoned a mid-career physician who’s known to her colleagues as a “doctor’s doctor”—someone every physician looks up to and respects. She, too, is suffering.

“Most nights, it takes me hours to fall asleep,” she said, “and then I wake up before sunrise covered in sweat.”

The third, a senior attending with over 30 years of experience, said things were as bad as he could remember: “Last week, I lost four patients in a single day. I’ve never lost that many patients in a month.”

Dealing with death in physician culture  

Humans are emotional creatures. All of us experience grief, a normal and natural response to loss. And we all experience fear, a biochemical reaction to real or imagined danger.

And yet, for centuries doctors have been taught to disregard both. By repressing emotions and denying fear, physicians accomplish the remarkable.

For example, think back to the onset of the pandemic, when clinicians—lacking necessary protective equipment—donned garbage bags for smocks and salad lids for facial shields. Without hesitation, doctors passed tubes down the mouths and into the lungs of their sickest patients. And without exception, this attempt to restore breathing caused patients to cough and spew deadly virus into the air. Despite these hazards to their own health, doctors didn’t waver, nor could they take time to grieve when many of these patients died days later.

The willingness of doctors to care for the sick at great personal risk has earned them generations of admiration, gratitude, and esteem. But it now comes at a great emotional cost, as well. To help you understand the tremendously important role repression and denial play for doctors in life-and-death situations, let me tell a story about a patient I treated early in my career.

Meet Kathy 

The kitchen phone rang slightly after 8 a.m. on a Saturday. They needed me at the hospital. Within the hour, I was standing at the bedside of a 10-year-old girl with leukemia, a nasty infection, and a fever of 102.

Her name was Kathy and she was on her third course of chemo. A fiery red discoloration ran from her wrist to armpit. Her lightly freckled skin glistened with sweat.

My job was to figure out the source of her infection and treat it.

One possible source was cellulitis, a problem that’s literally skin deep. For that diagnosis, high-dose antibiotics would be the best solution. The other possibility was a deeper infection called necrotizing fasciitis. It’s a terrifying infirmity that attacks like a two-headed snake: inflaming and swelling the underlying muscles, thereby shutting off circulation and stopping the antibiotics from reaching their target. With this diagnosis, saving Kathy’s life would require urgent and radical surgery. I’d have to flay the full length of her arm, incising the skin and underlying tissues, deforming the young girl forever.

I explained the potential causes and treatments to Kathy’s parents, noting that the odds of each were approximately the same.

Overwhelmed with fear, the father asked, “What would you do if this were your child, Dr. Pearl?”

It was a logical question. Neither parent had the medical expertise to make the decision. Yet, it caught me completely off guard. The painful truth was I had no idea what to do.

But to say those words aloud, “I don’t know,” seemed unconscionable. A decision had to be made. It was at this moment that the culture of medicine came to my rescue. All those years of training filled me with a kind of assuredness that defied the facts of Kathy’s situation.

“I would operate,” I said with confidence.

Denial, repression, and omnipotence 

Medical culture doesn’t endow doctors with all the answers. But it does, on occasion, lend them a sense of omnipotence, allowing physicians to repress their anxiety and doubt, leaving them with the aplomb to act decisively.

I was right about Kathy’s diagnosis. As I incised through the skin and subcutaneous tissues, necrotizing fasciitis was there, staring back at me. What should have been a beautiful network of healthy tissues had turned purulent, necrotic, and slimy.

We operated for almost three hours. The surgery was successful. Over the next two days, Kathy seemed well on the road to recovery. But on post-op day three, I was stat-paged from my clinic downstairs, took the elevator up to the seventh floor, and rushed to her room where I found the girl lying unconscious and motionless. As infection raged throughout her body, Kathy’s pulse flickered away. Her blood pressure plummeted. Within minutes, her heart stopped.

A code red rang over the loudspeaker. The pediatric critical care team rushed in to resuscitate her.

“Paddles, clear, shock.”

“Increase the voltage! Clear, shock.”

“Again! Clear, shock.”

They did everything they could.

I glanced at the clock on the wall. The hour hand pointed to four. The minute hand stood upright. The pediatric intensivist turned to the nurse: “Time of death, four p.m.”

As the physicians exited the room, I stared at Kathy’s lifeless body. I took off my gown, removed my gloves, and knew what I had to do next.

In the corner of the room, under my breath, I recited the impossible mantra—words I’d learned early in my training: “Please sit down. I have terrible news. Kathy died this afternoon. We did everything we could. I am so sorry.”

Kathy’s mother and father joined me in a quiet room near the waiting area. I looked them in the eye and confirmed their worst fears. We sat in silence as tears flowed down their cheeks.

Years of learning to repress my emotions gave me the strength to keep my eyes dry, just as years of denying doubt gave me the ability to pick up a knife, cut Kathy open, and remove every strand of disease and decay I could find.

As doctors, we are given a sacred trust. We are expected to preserve life. It is our highest duty. Losing a patient like Kathy carries the crushing weight of defeat. It always does. But in the moments after, the culture of medicine proves curative and restorative. It instills in doctors the ability to move forward.

I tossed and turned in bed that night, replaying every decision I made. But by morning, I got myself out of bed. Back at the hospital, two parents were waiting for me to repair their daughter’s cleft lip. That child deserved and received my full attention.

When every day brings another Kathy 

The difference between my experience with Kathy and that of the doctors treating COVID-19 patients isn’t the intensity of pain that comes from losing a patient. It is the frequency with which it happens.

Throughout my surgical career, I lost maybe three dozen patients—about two a year—most from cancer. I can’t imagine how I would have felt losing four Kathys in a single day.

No degree of grit or toughness or repression can prepare a physician for the deluge of death this pandemic has wrought. No amount of cultural conditioning could adequately prepare doctors for what they’ve endured.

Unable to deny the inevitability of death, doctors are paying a steep price for denying their emotions. Under constant bombardment, their defense mechanisms act more like fine-grained sieves than solid steel pots. Physicians can’t keep all the psychological discomfort inside. Increasingly, they feel overwhelmed, defeated, and lost.

Dealing with a doctor’s trauma 

With millions of COVID-19 vaccine doses being administered each day, doctors may be nearing the end of their acute trauma. On the other side of it, two terrifying threats await: post-traumatic stress and a static culture of medicine that dissuades doctors from seeking professional help.

Physicians are taught to sacrifice, overlook pain and keep a stiff upper lip. These lessons weren’t designed to boost their psychological health. They’re meant to get doctors through the day. It might have worked for generations past, but in the face of unyielding death and loss, these rigid prescriptions prove inadequate.

To figure out what’s being done to address the pain of doctors today, I reached out to a critical care physician involved in resident education. He told me that a psychologist is now available to all doctors at the hospital where he works. They can schedule a confidential, no-cost appointment at any time.

This is a good start for those doctors. But it’s a resource unavailable to most U.S. physicians. And even if all caregivers could easily access mental health services, medicine’s “tough-it-out” culture of denial and repression sits firmly in place, impeding their progress.

A call to action

Approximately 400 physicians die from suicide every year. Thousands more report feeling exhausted, depressed, and on the verge of quitting the profession. We can’t afford to lose more doctors. We must act now.

PTSD (post-traumatic stress disorder) occurs after the trauma, not during it. Therefore, I urge residency directors and hospital administrators to establish programs now to help clinicians acknowledge their grief and get the help they need—before it’s too late.

The lessons of this pandemic leave me with two conflicting thoughts about the culture of medicine. First, it would be a mistake to reject and discard the mission-driven values, beliefs, and norms that have supported doctors for centuries. At the same time, it would be a mistake not to evolve the culture of medicine to address the needs of doctors and patients today.

Robert Pearl is a plastic surgeon and author of Uncaring: How the Culture of Medicine Kills Doctors and Patients. He can be reached on Twitter @RobertPearlMD.

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