Even as the United States slowly opens back up with restrictions on nonessential businesses easing, coronavirus disease 2019 (COVID-19) has left an indelible mark on human history. The full impact of the lives lost and the disability caused by COVID-19 are only part of the picture.

Oncologists, just like their patients, are facing an unprecedented emotional burden from the COVID-19 pandemic. First-line responders are at especially high risk of experiencing psychological hardship from the burden of disease, death, and anxiety, whereas oncologists, in particular, are feeling the strain of worried patients, financial hardship, and uncertainty about the future.

Even during ordinary times, women physicians, resident physicians, and medical students face higher rates of depression than the general population.1,2 Every year, it is estimated that 400 physicians take their own lives, with women physicians facing a much higher risk of suicide than the general population.3 Increased emotional stress from these difficult times may increase the risk of depression in physicians. Sadly, the toll of COVID-19 has already resulted in the loss of one of our emergency department physician colleagues.4

Emotional Contagion Emotions, just like viruses, are contagious. Psychologist Steven Cohen, PsyD, notes that physicians, just like all others, are at risk of internalizing the negative feelings of the people around them. Physicians who work in a daily atmosphere of severe emotional distress, fear, and worry, must take special precautions to avoid being overwhelmed by these negative emotions.

According to Cohen, the first step to managing emotional distress is to simply acknowledge and examine our emotional reactions. Physicians often experience guilt, anxiety, or shame when powerful emotions like sadness or anger are experienced. This discomfort leads to the repression of feelings. Because unexamined emotions lead to distraction, inattention, irritability, emotional exhaustion, and burnout, Cohen says that it is essential to acknowledge and reflect on these feelings.5 This is especially important for oncologists who face emotions involved with patient death. Traditionally, grief in medical training has been considered weak or unprofessional, and doctors have been encouraged to suppress their feelings. Rather than openly expressing grief, physicians instead use the technique of compartmentalizationputting the painful emotions into a metaphorical sealed box.

Healthy coping mechanisms such as acknowledging feelings and accepting support from others are important to practice.

Physicians are often reluctant to share negative emotions with others. It is critically important to open up about feelings with a family member or trusted friend or colleague.

In some cases, reaching out to a professional to help cope with powerful emotions is important. Asking for help is not a sign of weakness. In fact, it takes more courage to ask for help than it does to suffer in silence.

One of the dangers to sudden traumatic events like the COVID-19 pandemic is that they can trigger sudden, intense feelings of helplessness and hopelessness, which can provoke suicidal thoughts even in people without any underlying mental conditions, says Cohen. He notes that receiving adequate mental health care at the time of the serious event may help physicians to have improved emotional and cognitive resilience to withstand the impact of the trauma.

To get the best result in managing depression symptoms, physicians must work with a trained clinician in a structured fashion. Avoid self- treatment or using friends or colleagues informally for medical care. Instead, ask a trusted colleague or your primary care physician for a recommendation to a psychologist.

Although physicians often worry that seeking psychological help may have an adverse effect on their career, there are ways to get help conf identially or even anonymously. For example, both the Collier County Medical Society and the Lee County Medical Society in southwest Florida provide free and completely confidential sessions for physicians in the community. Others, including the LifeBridge Physician Wellness Program, offer a free toolkit that helps organizations start confidential programs for doctors.6

Well-known factors associated with physician depression include lack of sleep, dealing with death, making mistakes, 24-hour responsibility, self-criticism, and difficult relationships with coworkers and patients.7

Physicians must acknowledge the need for self care.8 Take time to manage the physical needs for adequate sleep, nutrition, exercise, recreation, and social activities. Avoid turning to maladaptive techniques of self-care. Acknowledge that despite best efforts, failures can occur.

Although these are difficult times, look to others for support. Physicians are incredibly resilientcompleting medical school, internship, and residency takes incredible fortitude. Everyone just needs a little help from friends, family, each other, and perhaps, a good psychologist.

Rebekah Bernard, MD,is a family physician in Fort Myers, Florida, and the author of Physician Wellness: The Rock Star Doctors Guide.This article originally appeared in Medical Economics.

Reference:

1. Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. 1999;156(12):18871894. doi:10.1176/ajp.156.12.1887

2. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81(4):354373. doi:10.1097/00001888-200604000-00009

3. Sargent DA, Jensen VW, Petty TA, Raskin H. Preventing physician suicide. The role of family, colleagues, and organized medicine. JAMA. 1977;237(2):143145. doi:10.1001/jama.237.2.143

4. Watkins A, Rothfield M, Rashbaum WK, Rosenthal BM. Top E.R. Doctor who treated virus patients dies by suicide. New York Times. Published April 27, 2020. Updated April 29, 2020. Accessed June 10, 2020. https://nyti. ms/2AAtxwu

5. Granek L, Tozer R, Mazzotta P, Ramjaun A, Krzyzanowska M. Nature and impact of grief over patient loss on oncologists personal and professional lives. Arch Intern Med. 2012;172(12):964-966. doi:10.1001/ archinternmed.2012.1426

6. LifeBridge Physician Wellness Program. Working to mitigate physician burnout. Accessed June 10, 2020. https://bit.ly/38yPI2R

7. Bright RP, Krahn L. Depression and suicide among physicians. Curr Psychiatry. 2011;10(4):16-30.

8. Bernard R. The 5 elements of physician self-care. Medical Economics. November 6, 2019. Accessed June 10, 2020. https://bit.ly/2CbEPrx

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Coping With Physician Depression in the Era of COVID-19 - Targeted Oncology