Seeing red flags
Kim was the first of the three residents to treat a COVID-19 patient.
He was younger than she’d expected and otherwise healthy. She remembers looking at him and thinking:
And he was. He recovered quickly and was discharged from the hospital.
The happy ending did not prepare her for what was to come.
Long shifts at the hospital spilled over into her dreams. “In July,” she said, “a lot of the dreams that I had directly related back to this one question: Am I ready to be here?”
That month, Wisconsin’s daily COVID-19 cases more than doubled, reaching 1,117 with six deaths on July 31.
At the end of her first month of residency, Kim wrote a short essay.
“The first time I was summoned to pronounce a patient’s time of death, I stared at my pager wondering if they’d contacted the wrong person,” she wrote.
“As I move through my days, I experience twinges of incompetence. I fear that a patient might call me out. Of course, this is a familiar theme for many during the pandemic. None of us has the faintest idea where this is headed, and uncertainty lingers over all of health care.”
Residents constantly faced the vastness of what they did not know. But Kim suspected that this was a time when the entire medical community was in the dark and needed to be honest about it.
“Do even the most confident attending (physicians) have moments of distress?” she wondered in her essay. “Is there, in this moment, an opportunity for of us to acknowledge our hidden feelings of inadequacy and hesitation?”
Impostor syndrome
Marc, too, struggled with hesitation and self-doubt.
In the hospital hallways and patient rooms, residents learn a delicate balancing act central to the practice of medicine, the need to be both planner and doer. Calm and considered but also quick and decisive.
Physicians, Marc explained, perform an operation three times: the first as they walk to surgery, thinking ahead and running through each step; the second during the actual procedure; and the third, afterward when they replay what happened.
Before becoming a resident, Marc had never felt the full weight of that process.
“As a medical student,” he explained, “you live in this abstract place where you can think about the plan and then present the plan. But now you have to be the one who carries it out.”
Now, patients would lean over to check his identification badge and jot down his name. Other doctors watched him. He was always aware that his work could wind up being critiqued at one of the weekly or monthly in-hospital conferences.
In this new role as Dr. Drake, Marc recalled that he would walk into a patient’s room thinking: OK. Game time. Then his pensive nature would kick in. He would freeze for just a moment.
He would take a deep breath, acknowledge the situation in the room, and remind himself: I do belong here.
The hesitation offered a window into a larger phenomenon experienced by many new workers, but especially doctors: Impostor Syndrome. The syndrome was first identified in 1978 by psychologists examining high-achieving women.
“Women who experience the impostor phenomenon maintain a strong belief that they are not intelligent; in fact, they have fooled anyone who thinks otherwise,” wrote the authors, Pauline Rose Clance and Suzanne Ament Imes, in the journal Psychotherapy: Theory, Research & Practice.
Although the fear of being exposed as a fraud can affect any new employee, it is especially acute in medicine where the stakes are quite literally life and death.
A 2016 study of 130 American medical students found symptoms of impostor syndrome in 49% of female students and 24% of male students. A 2008 study that focused exclusively on medical residents in a Canadian hospital found feelings of impostorism in almost 44%.
“There will be a first day that you run a code (for a medical emergency). There will be the first day that you lose a patient. There will be a first day for a lot of things,” said Masood, the psychiatrist who treats doctors near Philadelphia.
Moreover, since residents make the rounds of all patients on a floor, they’re in a better position to break away quickly and respond to an emergency. The more experienced attending physicians tend to spend more time with individuals and may be in the midst of discussions they cannot abandon in an instant.
Often it is the residents who arrive first.
In 2020, especially in the early months of the pandemic, it was all too easy to feel like an impostor — not only for residents but for doctors with many years of experience.
“We don’t have a treatment algorithm. We just don’t know what we’re doing, and anything we’re doing isn’t working,” said Michael F. Myers, summarizing comments he heard from doctors early on at a support group at the State University of New York Downstate in Brooklyn. Myers wrote the book, “Becoming A Doctors’ Doctor: A Memoir,” about his 35 years as a psychiatrist specializing in the treatment of physicians.
As Myers was hearing desperation in his small support group, Masood was reading troubling posts in a Facebook group frequented by thousands of health care professionals. Doctors felt exhausted and overwhelmed by the mass of extremely ill and dying patients.
One post, in particular, lodged in Masood’s memory:
“The first time I was summoned to pronounce a patient’s time of death, I stared at my pager wondering if they’d contacted the wrong person.”
Does anyone know a good lawyer to write a will?
“It became a red flag,” Masood said. She responded quickly, putting out a call for all psychiatrists willing to counsel doctors for a new Physician Support Line. Almost immediately, 50 volunteered. Then 100. In the first two days, 200 psychiatrists signed up.
A year later, more than 800 psychiatrists across the nation staff a telephone support line that has surpassed 3,000 calls.
“Everyone is looking to the doctors to have the answer to this thing,” Masood said. “In some ways, the expectations of the nation were put on this group of people who’d never seen this before either.”
Residents phoning the support line described their fear of catching the virus in their hospitals. Masood recalled one common refrain: “We’re the ones seeing the patients. It often feels like we’re the sacrificial lambs.”
Facing the virus
In August, Marc carried out his first tracheotomy on a COVID-19 patient.
The surgery opens a direct path through the neck and into the airway so that doctors can insert a breathing tube.
Marc knew that many of those infected with the virus were undergoing tracheotomies, and he knew the procedure put doctors at especially high risk of becoming infected. Scientists had determined that COVID-19 spread through droplets, some as fine as mist or aerosol.
Marc performed the tracheotomy not knowing whether his patient had COVID-19.
“You’re there, centimeters from their lungs looking into the opening where the breathing tube gets placed,” Marc said. “You have all of your Personal Protective Equipment on, but your mind starts to spiral. Did I put on my PPE correctly? Did I pinch the nose of the mask correctly? Are my glasses falling off my face?”
Soon after the procedure, Marc learned the patient had tested positive for COVID-19. The man became a vivid reminder of what was at stake each day.
After the surgery, Marc cared for him for another two months, but the patient remained in the hospital for twice as long. In the end, doctors could not save him.
“I can picture his face clear as day,”
Marc would say a year later.
Focusing on the patients
Hospital staff trained extensively, following detailed instructions for donning and removing protective suits, gloves and masks.
During practice runs, the equipment was laced with dye only visible under ultraviolet light. “If we’d gotten any of the dye on us, we’d compromised ourselves,” Jamie said.
Outside the room of every COVID-19 patient, the hospital posted laminated cards detailing safety procedures. Jamie didn’t need the cards. He had committed the checklist to memory.
Steps included rubbing hand sanitizer over the gloves to kill any molecules of virus that might have come from the patient. Doctors were told to remove their gowns and roll them away from their own bodies. Gowns went straight into the trash.
“You’re seeing some really sick patients with weakened immune systems,” Jamie said. “You think about how easy it is to transmit this infection. You’re constantly reflecting on the impact and consequences if you aren’t doing it right, if you’re not wearing a mask properly.”
Jamie learned to work around the barrier that the protective equipment placed between himself and his patients.
He understood the necessity. Every day, doctors were questioning their own coughs. Is it seasonal? Dryness in the throat? Or the virus?
Jamie made sure to sit beside the patient’s bed. He never wanted to be looking down on the patient, a posture that might add to their feeling of powerlessness.
Even though his face was covered by a mask, he controlled the muscles. He composed himself so that if he felt stress or fatigue, it would not show. He would ignore the bustle of the hospital.
All that mattered was the patient in front of him.
“You have to learn to over-emphasize the use of your eyebrows or your voice intonation to convey information,” he said. “You want to be able to demonstrate good news.”
When he spoke, he avoided medical jargon. He kept his voice soft and reassuring. He spoke slowly, pausing to allow each new piece of information to sink in.
Projecting calm was crucial when treating the most severely ill COVID-19 patients, those struggling to breathe.
“In their eyes you see fear, anxiety,” Jamie said. “That sensation that you cannot breathe — there are other lifethreatening conditions, but I think your ability to breathe is probably the most psychologically provoking to the body. It’s such a tangible thing. You see the patients, they’re terrified and it gives us anxiety, too.”
He felt it essential to hide any anxiety. “I’m calming,” he said, “and trying to give them hope.”
has written in-depth stories about health, science and research for the Journal Sentinel since 2000. He is a three-time Pulitzer Prize finalist and, in addition, was part of a team that won the 2011 Pulitzer Prize in Explanatory Reporting for a series of reports on the groundbreaking use of genetic technology to save a 4-year-old boy.
Email him at mark.johnson@jrn.com; follow him on Twitter: @majohnso.