Beth saw her first dead body of the day just as she was leaving the emergency department. Earlier, she’d admitted a patient with the coronavirus; now she was on her way to an upstairs doctor’s lounge to finish writing her notes. Standing by the elevators, lost in thought, she nearly missed the orange body bag as it was rolled out of the car that had just opened in front of her. She decided to take the next one.
Seconds later, another elevator opened behind her. She turned—out came two more stretchers, two more bodies. While she watched, every elevator in the bay opened its doors, expelling stretcher after stretcher of bodies. “I felt surrounded,” she said. “I’d never seen anything like it. I thought I might throw up.”
An endocrinologist by training, Beth—whose name has been changed for this story—usually sees patients in an office; when she first volunteered to help on the wards, she was nervous. As the pandemic deepened, she’d grown comfortable in her new role, or so she’d thought. She turned to a junior colleague with whom she’d been waiting. “I knew I had to be brave,” she said. “I kept it together for her.” Thinking back now, she recalls not just the orange bags but the young woman’s petrified face.
For many health-care workers, initial concerns about the rationing of ventilators, masks, and gloves have been replaced with the weighty recognition that the fight against COVID-19 is not a momentary disruption but a new way of life. More than a hundred and thirty-two thousand Americans have died of the virus, and the pandemic is still making its way across the country, with case counts spiking as states reopen. There are no game-changing treatments for the disease, and no vaccine. The pandemic will be sticking around for a while.
Even in normal times, health-care workers are at high risk for mental-health problems. Doctors commit suicide at twice the rate of the general population; a quarter of I.C.U. nurses have symptoms of P.T.S.D.; a third of residents show signs of depression; more than ten per cent of graduating medical students report having suicidal thoughts.For several years, Srijan Sen, a professor of psychiatry at the University of Michigan who studies the well-being of physicians, has been following medical residents in China, using an app that asks doctors there questions about their moods. Usually, as the Chinese New Year approaches, their collective mood improves; this year, when the pandemic cancelled celebrations, “we saw a pretty concerning decline in mood and increase in depressive symptoms,” he said.
Sen’s work is consistent with other recent research. A study of nurses and doctors caring for COVID-19 patients in China found that nearly three-quarters had experienced psychological distress; half reported symptoms of depression, and a third had difficulty sleeping. A preliminary study in Italy found that half of health-care workers there had symptoms of P.T.S.D. In April, these statistics became real for those in New York’s medical community, after two clinicians, an emergency physician and an emergency medical technician, died by suicide.
In his psychiatry practice, Sen cares for doctors struggling with mental health; these days, he works over Zoom. “There’s an increase in concern for patients, a feeling of not being able to do as much as they normally would,” Sen said. “Then there’s the added concern for themselves and their families. On one hand, they feel, ‘This is why I became a doctor.’ On the other, it’s, ‘I’m putting myself, my spouse, and my children at risk.’ ” In his prior work, Sen found that the prevalence and severity of mental-health issues varied from hospital to hospital. He believes that these disparities offer a lesson for this moment. “My sense is that stress and anxiety will be worse in places where clinicians feel that leadership is more concerned with finances than with safety, or is not being upfront about masks and P.P.E.,” he told me. “Ultimately, you want to know that your institution is behind you.”
Since the pandemic started, Jonathan Kochav, a cardiology fellow in New York City, has cared for hundreds of critically-ill COVID-19 patients. He describes his emotional state as having progressed through three phases. They mirror what I’ve heard from other doctors, and my own experience as a hospitalist working in coronavirus wards and I.C.U.s.
The first phase, which began as the virus started its explosive, relentless spread across the city, was imbued with excitement and fear. The excitement had to do with venturing into uncharted territory, unravelling the mysteries of a new virus and trying to subdue it. “We were learning on the fly, but, just by being at the epicenter, we were soon among the world’s most experienced at treating this disease,” Kochav said. The fear—of losing his patients, his loved ones, his own life—was equally unprecedented. “When I was first treating COVID-19 patients, I knew I would get it,” he continued. “I knew my wife would get it. I had visions of her being intubated in an I.C.U. I was scared my parents would get sick and die. I thought about which hospital I would bring them to.”
As it turned out, Kochav did get sick. So did his wife, who has also been treating people with COVID-19. The fear changed how he interacted with patients and their families. “Dealing with family members was particularly emotional,” he told me. “I saw my fears coming true in what they were experiencing. I could so easily project myself into their position.” A doctor can feel some distance from patients with chronic ailments, such as heart disease or diabetes. Not so with a virus that threatens to infect everyone.
As the weeks went on, Kochav experienced a gradual hardening: phase two. “When you’re exposed and exposed and exposed to something, it becomes less scary,” he said. “There was this desensitization and detachment.” He noticed colleagues who had previously changed into street clothes before and after shifts departing the hospital in scrubs; some forgot to put on eye protection as they walked toward patient rooms, scurrying back to collect face shields. His own approach to patients began to shift. Everyone had the same disease; many fared poorly regardless of what he did; treatment became mechanical. “I felt disconnected,” he said. “I’m not sure if it’s because I overinvested earlier and was just emotionally spent, or because every day was an endless stream of the same thing. But I went from seeing every patient as my mom, my dad, my wife, to seeing every patient as a lab value and ventilator setting.”
Others apparently felt the same way, because soon Kochav’s I.C.U. developed a plan to restore humanity to its work. The unit began asking families to send in photos and double-sided sheets describing each patient’s life and interests. Some families wrote from the first-person perspective of the patient—he was introducing himself. Soon, I.V. poles were covered with paragraphs describing years past and laminated pictures of children, grandchildren, vacations, and graduations. “I’d go to check a patient’s ventilator settings and suddenly I’d see their smiling face at a barbecue,” Kochav said. “I’m caring for people again.” He hopes this new, third phase will last.
Coronavirus patients go through phases, too. In early March, David and his partner, Emily, left the city with his sister and brother-in-law to stay on Long Island. (They asked me not to use their real names to protect their privacy.) David exercised six days a week and, at thirty-five, had never been seriously ill. When he woke up feeling unwell, he attributed his fatigue to a bad night’s sleep. That evening, he entered the kitchen, where his sister was eating a sweet potato; overcome by nausea, he started up the stairs, then fainted, hitting his head on a railing and opening a gash above his left eyebrow.
