No Shame in Choosing Not to Be a COVID-19 Hero

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This transcript has been edited for clarity.

Michelle L. O'Donoghue, MD, MPH: Hi. This is Dr Michelle O'Donoghue, reporting for Medscape. Joining me today is Dr Lisa Rosenbaum. She is a cardiologist with me at Brigham and Women's Hospital, and she is also a medical writer for The New England Journal of Medicine (NEJM). Welcome, Lisa.

Lisa S. Rosenbaum, MD: Thank you for having me, Michelle.

There are lots of good ways to be a doctor, not just our classic idea of never showing weakness.

O'Donoghue: I've always found your writing to be very poignant because there is an honesty to the way you write. You are also very willing to tackle controversial topics that make people a little bit uncomfortable, but I think that is really the mark of a great writer. I was really quite moved by a recent piece you wrote for the NEJM, titled "Once Upon a Time... the Hero Sheltered in Place." It got me thinking a lot about physicians and, more broadly speaking, all the first responders and frontline workers who have been tackling the COVID-19 virus during this pandemic and their bravery and selflessness.

I have spoken with many of my colleagues who have shared the exact fear that you were able to put down on paper so nicely, and a lot were people I thought would jump into any emergency situation without giving it a second thought. But you realize that everybody has their reasons for being concerned about their own potential morbidity and mortality when facing this virus, whether for family reasons or for personal health reasons. Everyone was really scared. You put a nice voice to that. In this era of not being fully aware of the mental health and the stress that is faced by healthcare workers, it's important to shine a spotlight on this topic. How did you come to write this piece and what are your thoughts on the subject?

Rosenbaum: First of all, thank you for reading anything I write. That makes me feel terrific. I have lupus and I'm on immunosuppressive therapy. As I talked about in the piece, when it first became clear that COVID-19 was going to be a big deal [overall] and in our hospital and across Massachusetts, I rather quickly made up my mind that I wanted to take care of patients as I usually would. I was scheduled for 2 weeks in April on our inpatient cardiology service. I sort of anchored on that in terms of how I was going to rejoin the world, because in the interim, I was home, like most people who didn't have to be anywhere, and I was writing. As time passed and we got a better sense of how severe the disease could be, my mom, who is also a cardiologist, was clearly having a hard time with my decision about being in the hospital during the potential surge.

I was watching this outpouring of courage among all of these people who were willing to risk their lives. I reported, for instance, about Italy when they were under siege. One of the young physicians was talking about his senior colleagues and said, "You see the fear in their eyes, but they want to help." And I had been with two friends in early March who both had had unfathomable losses in their lives and both were so eager to be on the front lines. Obviously, we saw this with all the essential workers who often did not have a choice about whether or not to work.

I got in my head that that was the right thing to do morally. I argued with my mother all the time, every time we talked about the upcoming clinical work. To cope with it, I shut her out emotionally which is not typical of us. I didn't know how else to manage. My younger cousin had died about a year ago, and on the anniversary of his death, my mother and I had a huge fight and did not speak for 2 days. My father, who is a rheumatologist, then sent me an email saying that they really did not want me to do this, so I called him on FaceTime.

As I was thinking about the narrative itself and what was happening, and also more deeply what was happening with our COVID-19 patients, there had been this whole aspect of dehumanization that I had not experienced because I had not been in the hospital — this idea that we can't see people and what that means for our ability to care. I felt like I was experiencing that with my mother on this level; I was able to shut her out and keep her at some remove. And then I saw her face when we FaceTimed that day. Her hair was up, which was unusual; she was wearing gloves, and she had been crying, which is also very much out of character. It suddenly hit me that I was hurting her so much and terrifying her, and that whatever risk-benefit calculus I was making (that I'm not sure I was making rationally) was maybe the wrong one.

At that moment I decided to back out. It was only after writing the piece when I heard from so many physicians, healthcare workers, or other people that I realized a lot of people had been grappling [like me]. They were grappling with their own risk, possibly the risk to family members or people they are exposed to, and also what that meant about who they were in terms of this heroic narrative that has become so much a part of our cultural conversation about all of this.

O'Donoghue: That makes sense to me because you mentioned that heroic aspect to it. I want to emphasize the courage that it took for you to be honest about your own personal experience and the decision that you made, because I think it helped so many. I think there was a sense of shame for people who were making decisions to say no for whatever the reason might be, but by you being able to state loudly why and how you came to make the decision that you made really showed a great deal of bravery in order to help others for whom, perhaps, serving on the front lines was not the right fit.

I was struck by one of the lines in your article where you mentioned a conversation that you had had with a physical therapist and that they were talking about how we work in a field where it punishes weakness, such as taking days off. It left me thinking about how even prior to the pandemic we've been seeing rising rates of suicide among doctors and lack of attention to the mental health of our healthcare workers.

During the pandemic I was saddened to hear reports such as the physician in New York City, Dr Breen, who took her own life after facing the stress of working in the emergency room. It's an opportunity for us to take a step back and think about this culture of medicine where we feel we need to tough it out and that it can be seen as a weakness to say "I need help" and "no." We need to recognize and respect — and even celebrate — the different reasons that people make the decisions they do.

Rosenbaum: I totally agree. We went into this with a more existential epidemic. We call it burnout, but it's really about so many different things. There is moral distress and also mental health issues; they sort of get lumped together. As a profession we don't do a good job of tackling those in a meaningful way. We are going to see the fallout of that as we emerge from this — and I hope we emerge from this. I think a lot of people are going to have some post-traumatic stress disorder. A segment among us will find this type of work purpose-giving and the very reason they went into medicine. For them, it's elevating.

But for another subset, it's not at all. It's very hard to address these issues in a way that is not superficial. Saying we care about your mental health and the whole thing with burnout and the yoga and self-care... it just misses the boat in terms of what people are really dealing with. I did not set out to address those issues more deeply, even though I was thinking about them a lot before the pandemic. But I think we have not found our way forward. In medicine, we talk about diversity but we don't follow through. There is diversity, obviously, in people's personalities and what they want and what they bring to the profession. We need to do a better job of saying that there are lots of good ways to be a doctor, not just our classic idea of never showing weakness.

O'Donoghue: Exactly. That is a wonderful note to end on, because hopefully, if anything, this pandemic will be a catalyst for some change. In many ways, we are seeing that in society overall. But hopefully, for the healthcare profession, there might be opportunity for this to be a turning point in terms of our understanding of stress and mental health for healthcare workers and making that a priority. Thanks again for joining me today, Lisa. I really appreciate it.

Rosenbaum: Thank you so much.

O'Donoghue: Signing off for Medscape, I'm Dr Michelle O'Donoghue.

Michelle O'Donoghue is a cardiologist at Brigham and Women's Hospital and senior investigator with the TIMI Study Group. A strong believer in evidence-based medicine, she relishes discussions about the published literature. A native Canadian, Michelle loves spending time outdoors with her family but admits with shame that she's never strapped on hockey skates.

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