Case Scenario #1

A 35-year-old patient, J.P., presented to my office with difficulty sleeping and anxiety about job performance. J.P. is a lawyer who started a position six months ago to assist unaccompanied minors seeking asylum. The patient has been feeling more anxious recently and worries that something might happen to the children in her family if she is not constantly watching them. J.P. has difficulty sleeping for more than three hours at a time and drinks as many as five cups of coffee during the day to combat low energy. I suspect that the patient's work might be causing these symptoms, but what is the best and most efficient way to confirm the source of J.P.'s stress?

Case Scenario #2

Earlier this year, my colleague, L.R., led an initiative at our clinic to integrate medication-assisted treatment for substance use disorder. L.R. often provides staff training sessions on this topic and incorporates stories of people who have experienced addiction and overdose as an educational tool. My colleague has recently been asking for last-minute coverage on their clinic days and has been increasingly delayed in closing charts. Staff have mentioned that L.R. has become uncharacteristically impatient and irritable. When they ask whether there is anything wrong, L.R. brushes off their concern, saying, “Everything is fine. My patients have it much worse than me.” What is the best way to approach my colleague about these changes in behavior?

Commentary

Many people, including health care professionals, law enforcement professionals, journalists, and lawyers, may encounter situations that result in secondhand exposure to trauma. Often, family physicians are vicariously exposed to the trauma of their patients as they share stories of domestic violence, war, gun violence, child abuse, homelessness, and life-changing diagnoses, including cancer and COVID-19. These clinical experiences can be compounded by other forms of witnessed trauma, including exposure to repeated violence portrayed in the news and social media. Chronic exposure to secondhand trauma can lead to vicarious trauma, whereby an individual internalizes the emotional experiences of others as though that individual had personally experienced them. Vicarious trauma can result in a change of worldview and disturb a person's sense of justness and safety of the world. See the Office for Victims of Crime toolkit¹ for a glossary of terms related to vicarious trauma (https://ovc.ojp.gov/program/vtt/glossary-terms). Unaddressed vicarious trauma can compromise a physician's ability to provide care or professional services and can affect their own personal health and relationships.

Risk Factors and Symptoms

Vicarious trauma is part of a spectrum of responses to trauma exposure, including secondary traumatic stress, caregiver fatigue, compassion fatigue, and burnout. These conditions have varying definitions and categorizations, with overlapping symptoms, diagnostic criteria, and management strategies.^2,3

Several personal and professional issues may predispose an individual to developing vicarious trauma. Factors that increase risk include a personal history of trauma, negative coping behaviors, a lack of social support, instability in non–work-related areas of one's life, and working with patient populations who disproportionately experience trauma.¹ Issues in the professional environment can also increase vicarious trauma vulnerability, such as excessive workload, unclear scope of work, and dissonance between institutional public-facing commitments to vulnerable populations and internal policies and incentives.³

Vicarious trauma symptoms can manifest in one's professional and personal life. For example, a physician who is usually affable and empathetic may become increasingly irritable toward patients and colleagues, distant with family and friends, or overprotective in parenting. Health care–related manifestations can include excessive worrying (e.g., that a patient missed an appointment because they are hurt or have died), delays in completing the charts of patient encounters that involve upsetting stories, overreacting to unexpected environmental noises (e.g., overhead pages in the clinic, telephones ringing in examination rooms), experiencing visual images of examining an abuse-related injury in a setting outside of work, or finding it difficult to watch previously tolerable entertainment (e.g., shows or movies involving crime and violence). Symptoms of vicarious trauma are similar to those of posttraumatic stress disorder, with domains of intrusive thoughts, avoidant behaviors, and alterations in arousal.⁴ The Secondary Traumatic Stress Scale is a validated 17-item questionnaire that was developed to measure symptoms associated with the indirect exposure to traumatic events because of one's professional relationships with traumatized individuals (Figure 1).⁴ This scale can be used to evaluate vicarious trauma–related posttraumatic stress disorder.⁵