PTSD presents differently in docs, and residents are especially vulnerable

By Naveed Saleh, MD, MS | Fact-checked by Barbara Bekiesz
Published April 8, 2024

Key Takeaways

  • Physicians are prone to experiencing traumatic events at work that can result in a diagnosis of PTSD; accompanying symptoms range widely—from fatigue and tachycardia to depression and flashbacks.

  • PTSD risk is highest during residency training, when physicians are less seasoned to deal with trauma.

  • As "second victims," physicians can engage in programs like the forYOU initiative, which provides tiered interventions—including peer support and professional counseling—to better navigate the emotional toll of traumatic experiences at work.

The DSM-5 recently changed diagnostic criteria for post-traumatic stress disorder (PTSD) to include work-related traumatic exposures. In particular, secondary traumatic stress and compassionate fatigue commonly characterize the emotional burden that physicians and other professionals who regularly deal with trauma must face. 

Residents, in particular, are at an increased risk of developing PTSD, given their involvement in frontline care and high patient volumes—and because they lack the training and experience of seasoned attendings.

It starts early

Physicians are particularly prone to work-related traumatic exposures, as most recently demonstrated by the hazardous environment cultivated during the COVID-19 pandemic. Other work-related exposures that can contribute to PTSD in physicians include patient illness, patient death, workplace violence, patient exposure to disasters, serious medical errors, and patient complications. These risks often make physicians “second victims.”

PTSD risk is highest in resident physicians. A cohort study published in JAMA Network Open found that 56.4% of the 1,134 interns surveyed reported work-related trauma, with 19% of those experiencing trauma exposure screening positive for PTSD by the end of the internship year.[]

By comparison, the 12-month PTSD prevalence in the general population was 3.6%. 

Risk factors predicting trauma exposure included White race, increased hours worked, and stressful life experiences at baseline. Risk factors linked to PTSD included White race, being unmarried, stressful life experiences during internships, and depression/anxiety at the end of 12 months of internship.

Although the researchers found no association between trauma exposure and specialty, an internship in surgery and psychiatry did predict PTSD.

How emergency medicine breeds PTSD

Among practicing doctors, emergency physicians may be at particular risk, according to one study published in the Western Journal of Emergency Medicine.[] Among 526 US emergency physicians surveyed in the study, 15.8% had PTSD. 

“Physicians have high rates of substance abuse and suicide, which may be mediated by underlying PTSD,” the study authors wrote. “[Emergency physicians] deal with multiple challenges such as the potential to witness death and trauma on a frequent basis, diagnostic uncertainty, high patient acuity, crowding, and circadian rhythm disruption that place them [at] elevated risk for occupational stress.”

Second victims

Physicians who are second victims are those who have been involved in an unanticipated serious medical error, an adverse patient event, or a patient-related injury.

According to the University of Missouri Health Care, whose forYOU program is a pioneer in  supporting healthcare providers, second-victim physicians may experience a range of feelings: They may feel responsible for unexpected patient outcomes, feel as if they failed the patient in some way, or doubt their own medical skills or knowledge base. It can take days, weeks, months, or years to process such feelings following exposure.[]

Physical symptoms experienced by second victims include the following:

  • Sleep disturbance

  • Fatigue

  • Tachycardia

  • Tachypnea

  • Diarrhea

  • Nausea/vomiting

  • Headache

  • Difficulty concentrating

  • Muscle tension

Psychological symptoms can include:

  • Depression

  • Anger/irritability

  • Discomfort at work

  • Isolation

  • Self-doubt

  • Flashbacks

  • Numbness

  • Fear 

  • Frustration

Stages of recovery

The forYOU initiative characterizes six stages in the second victim’s trajectory toward recovery. Stages 1-3, designated Impact Realization, often occur simultaneously.

  • Stage 1: Chaos and accident response: Error realized or event recognized, with attempts to stabilize the patient, accompanied by emotions and distraction affecting the HCP

  • Stage 2: Intrusive reflections: Rumination, self-isolation, and feelings of inadequacy

  • Stage 3: Restoring personal integrity: Acceptance and managing gossip of others, with fear also experienced

  • Stage 4: Enduring the inquisition: Realization of seriousness of event and disclosure to family, as well as dealing with litigation concerns

  • Stage 5: Obtaining emotional first aid: Seeking personal and professional support

  • Stage 6: Moving on: Dropping out, surviving, or thriving

Help for second victims

The forYOU program utilizes the Scott Three-Tiered Interventional Model of Second Victim Support.[] 

Tier 1 involves local support from a manager, supervisor, or fellow team member. This colleague can provide one-on-one counseling. Tier 2 involves trained peer support, such as patient safety officers and risk managers. Tier 3 involves an established referral network, including psychologists, social workers, and chaplains to help the HCP. 

What this means for you

Physicians often encounter traumatic experiences at work that can trigger PTSD, and resident physicians are more prone than seasoned attendings. As second victims, HCPs experience a variety of negative feelings and psychological or physical symptoms. Recovery is a multistep process, enhanced by formal programs available to provide support.

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