The unique exhaustion of healthcare moms

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For moms in healthcare, being a caregiver never ends.  Between work and home, they constantly care for others, often at their own expense. Recently, I spoke with five moms from different regions of the country who have worked on the front lines of the pandemic, either in a critical care/ICU setting or in the emergency room.

The five — Alicia, Kristin, Maya, Michelle, and Sarah (all pseudonyms to protect their privacy) — described how the anxiety and adrenaline that characterized the early days of the pandemic gradually morphed into exhaustion and empathy fatigue. They grappled with the fact that healthcare workers have gone from being heralded as “heroes” to being dismissed as “liars.” And they spoke about what it was like to be surrounded by death and trauma, and then have to pull it together so they could go home and parent their kids.  

As Michelle, an emergency room PA told me, “The problem for women in healthcare is that we give so much—and the job demands so much—of our emotional, physical, and mental energy that we are completely drained. That means our families get what’s left over, and we get even less. And that’s a terrible order of priorities.”

The pandemic has forced individual healthcare workers to re-evaluate their work as the system itself faces a host of complex problems that existed before COVID-19 and have only been exacerbated since. The five moms I spoke with told of their sacrifices and the challenges they have faced.

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“In the beginning, we just ran on adrenaline”

Each spoke about the palpable fear and, as one put it, “all-consuming panic” that characterized the pandemic’s early days.  So much was unknown, and they all worried that they might be risking their own—and their family’s—lives simply by going to work. 

Kristin, a critical care physician, weaned her daughter because she was afraid to nurse while treating COVID patients.  Michelle, who was redeployed to the ICU during the first wave of the pandemic, recounted gripping the steering wheel when she drove home so that she didn’t accidentally touch her face. Once she arrived, she changed clothes in the garage and ran into the shower. “I had to train my kids not to hug me when I came home”. 

Alicia, another critical care physician, can relate. She told me that her kids still ask permission to touch her when she comes home from work. Her institution went so far as to offer frontline healthcare workers free will-planning sessions with attorneys, a benefit that was both appreciated and deeply disconcerting.

The fear was particularly acute for Sarah, who was finishing her emergency medicine residency when the pandemic hit. The hospital she worked for was severely under-resourced and could not procure proper PPE for staff. On good days, she would have access to a paper surgical mask and gloves, but she never had access to a N-95 even though she was intubating COVID patients. On her commute home, she would scream to release the overwhelming anxiety.

“It was a sacrifice for my whole family”

Guilt about not being at home during the pandemic has weighed on these moms. In March 2020, Maya moved out of her house and into a separate part of her parents’ home. As a bedside ICU nurse, the prospect of bringing the virus home to her family terrified her, but the isolation was a challenge.

Being apart was also tough on Maya’s husband, who was trying to figure out how to work from home while juggling Zoom school and other parenting responsibilities for three kids without help. When Maya returned home, she continued to wear a mask inside her house until June 2020. She choked back tears as she recalled the first time she felt comfortable enough to unmask and kiss her kids. It had been more than three months.

Similarly, Michelle’s husband took primary responsibility for the kids and adjusted his work hours to fit her schedule. That meant they essentially were ships passing in the night, swapping childcare responsibility back and forth. Childcare was also challenging for Sarah, whose parents typically helped watch the kids.

Fear of exposing their parents and in-laws to the virus was a common theme, and many women delayed seeing their extended families as a preventive measure. Meanwhile, all five moms expressed concern for the impact the pandemic had on their kids’ well-being and mental health.

Kristin’s oldest daughter is very sensitive and exhibited signs of anxiety, talking frequently about COVID and climbing into her mother’s bed in the middle of the night to make sure she was there. Sarah’s kids went through a period of intense clinginess once schools reopened in the fall of 2020. Alicia’s younger son also had a hard time. She kept him out of pre-K and felt he spent most of the year depressed and isolated.

“You can’t imagine the horror of the things we saw”

Critical care and emergency medicine providers have a very high baseline tolerance for trauma. Put frankly, they are used to seeing horrible things.  However, the women I interviewed found the scale and persistence of death during the pandemic to be overwhelming.  

From the beginning, Maya’s employer decided to direct all COVID-positive ICU patients across the entire health system to her hospital, which meant they were constantly inundated with new cases. At several points, the ICU was at capacity, with critically ill COVID patients overflowing into the ER. Death literally was inescapable, Maya said.

“I was here, but I wasn’t,” she told me, noting she had trouble sleeping and often felt distracted and depressed at home. “It’s evident that I have PTSD, but between work and parenting, when do I have time for [addressing] it?”

The Delta wave hit Kristin’s region hard. She described the overwhelming number of “cold, awful deaths”. The healthcare workers on her unit started emotionally detaching to survive; they encouraged her to “care less” — advice that felt discordant with her values and the type of medicine she wanted to practice.

Around this time, Kristin started experiencing nightmares and intense feelings of guilt. She became closer to her colleagues but found it hard to relate to family and friends outside work, worried that she would burden them with descriptions of the horrors she had seen. Like Maya, she knew she needed therapy but has not yet followed through.

“To be functional, you have to compartmentalize work,” Alicia told me. “We bury the trauma to get through the day.”

“All the cracks in medicine were just blown open”

Much can be said about the systemic problems at play in medicine, but hierarchical tensions and institutionalized sexism were specifically highlighted during these interviews.

To preserve scarce PPE and limit potential exposures, many hospitals restricted direct access to COVID patients during the first wave. Each institution handled this differently. Sometimes attendings managed care from a central station while bedside nurses, residents/fellows, and respiratory therapists carried the bulk of the responsibility for direct patient care. At other hospitals, only nurses and attendings were allowed to have direct contact. Regardless of the configuration, it highlighted the power differentials that exist in the medical hierarchy and left those required to assume the most risk feeling, as Maya put it, “like our lives mattered less”.

A senior resident during the first few months of the pandemic, Sarah felt that she carried a disproportionate share of the risk. She recalled a time when an attending rushed her into a patient room without a mask, demanding she “just intubate”, while he stood safely outside the door observing. Additionally, as the only mother in her residency program, Sarah regularly felt judged for her parenting responsibilities. When schools shut down, she was shocked to find that her male colleagues with kids were met with compassion and given lower patient loads; Sarah was told she “needed to be more positive” and should focus more on work and less on family.

Kristin, one of the only women in her section, is regularly asked to perform menial tasks like taking meeting notes because she’s “naturally good at it”. When the other junior female physician on her team paused her clinical work because she was pregnant during the pandemic, the backlash was swift. Kristin felt obligated to overcompensate and take on even more shifts after male colleagues made comments about how women doctors were unreliable.

“I’m so tired. I don’t know how much longer I can keep going”

Unsurprisingly, all five women spoke about their bone-deep, all-encompassing exhaustion. They are exhausted by the politicization of the virus, the vilification of healthcare workers, and the mistreatment and lack of respect they’ve experienced from patients, patients’ families, and colleagues. But most of all, they are exhausted by the pandemic’s relentlessness.  Some question how much longer they can continue to function like this.

Kristin is thinking about leaving medicine altogether, despite wanting to be a doctor since she was a child and training at some of the top institutions in the country. “I’m just not the same person I used to be,” she told me.

Maya, who takes great pride in the 14 years she has spent working in critical care, reached a breaking point earlier this winter. After her hospital refused to make changes that she and her colleagues had thoughtfully advocated for, she quit her job as an ICU nurse and accepted a position in a less intense post-op unit. With emotion evident in her voice, she told me: “I feel like I’ve been fighting this thing that’s impossible to fight, and I just couldn’t do it anymore.”

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Moving forward

Unlike many industries, healthcare is often described as a “calling” as opposed to a “job”. A calling implies an internal sense of purpose and emotional connection to one’s work. It is thought this deeper connection helps buffer providers from the sacrifices they make. But for many, this narrative no longer resonates the way it once did.

Much has been written about healthcare burnout since the pandemic began, but framing it in this way is imprecise. “Burnout” is an individual problem in which the provider has become detached, depleted, and less effective. It does not account for the influence of systemic failures, nor does it acknowledge the trauma, grief, and sense of helplessness many providers experienced during the pandemic.

Instead, what many providers may be experiencing is “moral injury”, which occurs when a person feels they have violated their moral code when they take part in, witness, or fail to prevent acts that are incongruous with their beliefs and values. Moral injury is distinct from, but frequently co-occurs with, PTSD. Applying the concept to healthcare workers, the National Center for Posttrauamtic Stress Disorder says:

During pandemics, some healthcare workers may feel like they must choose between caring for infectious patients and keeping their families safe, especially if they have elderly or at-risk family members or children in their lives. Moral injury can also develop in healthcare workers when they are present for end of life scenarios that are counter to their beliefs about how people should die, such as patients dying without loved ones present. Some workers may feel guilt and shame because they felt numb in the face of suffering and death. On rare occasions, healthcare workers may witness what they perceive to be unjustifiable or unfair acts or policies that they feel powerless to confront.

Healthcare workers and systems face complex problems for which there are no quick fixes. However, ethics consultant Suzanne Shale asserts that acknowledgment —defined as “a combination of deep listening, altered understanding and mutually agreed reparative action” — is key to healing moral injury. In her model, frontline workers and institutional leaders engage as equals in frank conversations to move towards mutual accountability and remedy.

As we enter the third year of this pandemic, I’ve thought a lot about what I want to teach my children about this experience. Certainly I want to impart the importance of compassion, fortitude, and collective responsibility. But I also keep coming back to something Alicia shared, “Sometimes the best thing you can do is sit beside someone in their suffering.”

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I want to cover what’s important to YOU.  I welcome reader input in deciding what and who to write about.  Email me at drjessicawilen@gmail.com and put “newsletter idea” in the subject.  

Much gratitude to Glenn Cook for his editorial assistance.