The first time I called time of death, I thought, “This is the absolute worst part of my job and I never want to do this again.” I was out of breath, having just run back up the stairs after getting a frantic phone call from the nurse. I had just left my patient’s room moments ago; she was in stable condition with her five sisters and her mother by her side. When I returned, they were in tears and the mother was on the verge of passing out. After they left the room, I performed a careful death exam, struggling to listen for absent heart sounds over the wailing cries of her sisters in the hallway. “Time of death, 3:22 p.m.” I stumbled through some version of “I’m so sorry for your loss” before I ran to the supply station to find an oxygen tank for the now pale mother. As a second-year family medicine resident, it was an awful experience.

Fast-forward to several months deep into the COVID-19 pandemic. As a new attending physician supervising residents in training on the inpatient wards, I soon learned that in fact, the death exam is one of the more straightforward parts of my job. The actual worst parts of my job are the daily roadblocks that prevent me from practicing the art of medicine. Every physician has a superpower; mine is connection and empathy. When the reality of the triple-layer of N95 mask, surgical mask, and face shield started interfering with my ability to utilize my superpowers, I quickly suffered one moral injury after another.

Moral injury in physicians happens when one is prevented from achieving his or her purpose. Many physicians look to the updated version of the Hippocratic Oath, penned by Dr. Louis Lasagna, for inspiration and guidance in defining their purpose: “I will apply, for the benefit of the sick, all measures [that] are required… I will remember that there is art to medicine as well as a science and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug …” (1). Repeated moral injury leads to burn out, which can include symptoms such as exhaustion, detachment, and helplessness. When the pandemic unveiled the inadequacies, inefficiencies, and inequities of our society and healthcare systems, physicians started to burn out at astounding rates. In a national survey of healthcare workers, conducted between May and October of 2020, 47.7% of physicians and 50.5% of resident physicians reported multiple symptoms of burn out (2). These symptoms have likely contributed to physicians leaving medicine at four times the rate compared to before the pandemic (1.14% of physicians stopping practice in April 2020 compared to 0.33% of physicians in April 2019) (3).

Despite these unexpected challenges, physicians have found strength during the pandemic to care for patients through the barriers of personal protective equipment, vaccine hesitancy, and social distancing. Across the country, inpatient services quadrupled in size and our emergency back-up systems were activated many times during the first horrific COVID-19 winter. It is in our nature to troubleshoot issues, navigate barriers, and go through great lengths to save lives. But to what end? In a world of misinformation and distrust, how can we continue practicing medicine without constant moral injury? How can we buckle down and charge forward, when we ourselves are broken down and losing our superpowers? How can we inspire the next generation of physicians if we are emotionally depleted and physically exhausted?

I don’t know the antidote to moral injury and burn out. One thing I do know, however, is that my superpower remains the same: to connect and empathize with patients, colleagues, learners, and ultimately with myself. And even in the time of a pandemic, I can find ways to practice my superpowers. I fed tacos bite by bite to a patient with COVID-19 who had been laying on his stomach on oxygen for 25 days, a critical and uncomfortable strategy used to improve his breathing. Dr. B, the senior medicine resident, brought a cupcake to surprise our patient who was celebrating her 50th birthday in the hospital. The medical student, K, went back after team rounds to sit with our patient while he waited for his surgery. I asked to see pictures of grandchildren and I learned names of pets. I told patients how the vaccine has given me the confidence to hug my mom for the first time in a year-and-a-half.

I don’t know if it’s enough, this desire for human connection, but it has at least gotten me this far. Every day, I share my superpower and take strength from seeing others in action. If I list out the thousands of hands I’ve held through illness and through death, all the tiny daily victories I shared in, and the joy of science I experienced during this dark time, I guess being a physician in the time of COVID-19 may have taught me some of the most important lessons of my career after all.

Dr. Vivian Yang is a full-spectrum family medicine physician and core faculty of RUHS Family Medicine Residency. She is passionate about physician wellness, community outreach, and serving underserved patient populations.

Follow Dr. Yang on Instagram @vivyangmd

References

1. Lasagna, L. (1964). The Hippocratic Oath: Modern Version. Public Broadcasting Service. Retrieved December 1, 2021 from https://www.pbs.org/wgbh/nova/doctors/oath_modern.html.
2. Prasad, K., et al. (2021, May 16). Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: A National Cross-sectional Survey Study. EClinicalMedicine 35:100879. Retrieved December 2, 2021, from https://www.sciencedirect.com/science/article/pii/S2589537021001590?via%3Dihub.
3. Neprash, H. T. (2021, Sep 20). Physician Practice Interruptions in the Treatment of Medicare Patients During the COVID-19 Pandemic. Journal of the American Medical Association. Retrieved December 2, 2021 from https://jamanetwork.com/journals/jama/fullarticle/2784484.