“It’s funny, but our lives are pretty normal,” Brian, my overnight shift-mate, said as he donned his hair net, mask, gown and gloves before seeing a covid-19 patient.
Of course, physicians’ lives during the covid-19 pandemic have been nowhere near normal. But normalizing extreme circumstances is a skill we have honed since medical school to help us get through the everyday pressure of simply showing up to work, where many of our patients are in the midst of the worst day of their lives. Normalization might be an adaptation that helps us survive these short-term stressors, but will we pay an even greater price down the road?
When I commute to the hospital, I believe I see what Brian means. While my wife and many of her friends have rarely left home other than for groceries in months, we—like other essential workers—still maintain some of our everyday routines. I used to feel a sinking fear of missing out when pedalling past lively outdoor tables on my way to a shift. Now, most of those restaurants are boarded up, and I feel gratitude for those midnight rides to the ER while the rest of the city is closed down.
The majority of my friends communicate with colleagues through screens, but in the hospital there is a bustle of community. Though screened and masked, we share coffee, meals or water cooler conversations. Occasionally, a medical school classmate and I stand side-by-side in an ambulance bay and reflect on the “good-old days”—like old men sharing a stoop and talking about baseball. But instead of curveballs and batter’s stances, in our mask-muffled voices, we review signs that imply impending respiratory decompensation and intubation techniques. We reminisce replacing each other in the intensive care unit (ICU) during residency after 30 hours on-call and how often we’ve had to use the critical skills we learned there to help patients and their families navigate their proximity to death.
In the fluorescent light outside the ER, the deeper truth of Brian’s comment began to settle in. Even if the communal nature of working in the hospital has tempered some of the isolation we feel, and the structure and rituals of our daily lives have remained more consistent than for our non-medical friends and family, that alone does not account for the relative normalcy many of my colleagues and I have felt during this time. If this dystopian world of isolation and illness feels familiar to physicians, it’s not because the structure of our daily lives has remained consistent—it’s that extremely abnormal circumstances are a “normal” part of our lives. Years of sleepless nights, missed family outings, and daily life-or-death decisions have likely left us jaded to this unusual existence.
It somehow doesn’t feel so difficult to stay in a separate room or hotel after dangerous covid-19 exposures when you have already slept on a cot in the basement of a hospital miles away from loved ones many times before. When you have already learned how to distance your personal emotions from those of the tragedies surrounding you, how difficult is it to be asked to simply do it again, over and over? Is that not what our training was intended for? Was it not meant to help make the abnormal bearable so we can successfully do our jobs and carry the obligations that come with the work?
Nevertheless, traumatic stress reactions can be normal reactions to abnormal circumstances.1 And when these abnormal circumstances occur so often that they no longer feel wrong, our brains begin to practice a bias called “normalization of deviance.”2,3 It is often cited as the root cause of the Challenger disaster and is a well-known phenomena in settings like the ICU. When alarms continuously beep without being addressed, they begin to lose their ability to elicit an appropriate reaction to something dangerous. The important signal gets lost in the noise, and eventually the warning system breaks down. Similarly, when our careers have been built on years of extreme work hours, stress and isolation, this global pandemic might not feel so foreign.
But even before the pandemic, medical providers suffered from a high rate of burnout and suicide.4 Many expressed feeling distant from their families and unable to share with them the most difficult parts of their jobs. Some of us believed we were sparing others the tragedies that only we were oath-bound to manage. Now, when we seem to have just somewhat recovered from the first and second waves of the covid-19 pandemic, we find ourselves in the midst of a third with no end in sight to those daily traumas. Some wonder if burnout will prevent us from being able to provide care through the winter.5 Our coping mechanisms seem to be breaking down, but perhaps there has been an alarm beeping this whole time.
Andre, an Air Force paramedic who worked as a nurse in our covid-19 unit, asked me if we had ever received PTSD training. Most of his fellow paramedics in that unit were veterans of war, and shared stories of the traumas they had overcome. Some were involved in improvised explosive device (IED) detonations while another survived a failed parachute opening. But those who recovered credited daily exercises to recognise the symptoms of PTSD in their everyday life. They said this helped prevent it from overwhelming or debilitating them. “You have to identify what is ‘not normal,’” Andre said, “so you can differentiate it from what is, and contextualise it.” Avoidance here, brushing these experiences off as “part of the job” without addressing the underlying traumas associated with them, can be maladaptive and put us at significant risk for PTSD.
“On the other hand,” Andre explained, “in a warzone, normalization can be a helpful short-term mechanism to allow you to put yourself at risk, day in and day out, without it overwhelming you.”
When Brian and I finish our shifts and remove our N95 masks, the novelty of comparing the pressure lines they leave on our faces has grown old. I feel grateful for colleagues like this, who, because we have spent years training under the pressure-cooker of the emergency room together can help make shifts listening to covid-19 ravaged lungs and titrating oxygen delivery feel somewhat typical. Only now, as I stand nearly-naked doffing my contaminated clothes before planning my return home, I wonder to myself, “Maybe I don’t want this to feel normal.”
Christian Charles Rose, Department of Emergency Medicine, UCSF / Kaiser Permanente San Francisco, USA.
Competing interests: none declared.
- Center for Substance Abuse Treatment (US). Understanding the Impact of Trauma. (Substance Abuse and Mental Health Services Administration (US), 2014).
- Banja, J. The normalization of deviance in healthcare delivery. Bus. Horiz. 53, 139 (2010).
- Price, M. R. & Williams, T. C. When Doing Wrong Feels So Right: Normalization of Deviance. J. Patient Saf. 14, 1–2 (2018).
- Ariely, D. & Lanier, W. L. Disturbing Trends in Physician Burnout and Satisfaction With Work-Life Balance: Dealing With Malady Among the Nation’s Healers. Mayo Clinic proceedings. Mayo Clinic vol. 90 1593–1596 (2015).
- Allday, E. & Asimov, N. Bay Area health care workers brace for grim winter: ‘We are exhausted’. Chronicle (2020).