Transgenerational Trauma in the Medical Fraternity

Written by Dr. Sharath Krishnaswami

Dr. Koustabh, a junior doctor of Internal Medicine, stood at the foot of the patient. His mind a warbled mess of what the patient’s diagnosis was, what resuscitative measures he undertook and what was left to be done to the patient who got admitted the night before. Sleep crept upon his mind and if he closed his eyes, he would pass out in a jiffy. 

“What tests have you done for this patient? Don’t you know the patient has to undergo all the investigations before rounds?”, the Professor of Internal Medicine asked the Medical Resident. Only to be met with a confused stare. Nothing prepared the Resident who secured 3^rd rank in the entrance exam amongst a thousand candidates, and after having worked 72 hours in the past 4 days, to face the demands of a stretched workforce.

“You have been on duty for 24 hours, you have been seeing all the patients continuously. These patients are your responsibility. You are supposed to have asked the patient’s history, examined the patient, spoken to the patient’s relatives and develop a treatment plan for the patient. How can you do all this without having figured out what condition the patient is in?”

“Sir, I didn’t have time. The Emergency was busy with patients through the night, and I had to continuously attend to them” Dr. Koustabh answered, his voice nervous, his forehead, a bead of sweat.

“This is a private hospital! There aren’t too many patients! During our time 20 years ago, we manage an entire department. There were no seniors to report to and we had to work 48 hour shifts! Don’t give petty excuses!  You are lucky you have seniors here to guide you!” The Internal Medical Professor bellowed at him, further frightening him. Dr. Koustabh went stiff at his shouting. 

“You’ve done a CT scan, run the electrolytes and are also awaiting the results of a complete blood count, isn’t it? To rule out signs of an infection?” A consultant in the same department who was aware of the case, pitched in.

“Yes, yes, I have. And we are awaiting the consent from the family for an ICU admission.” Dr. Koustabh recollected and let the Team know. 

“When will you learn? How long must we keep guiding you like this?” The Professor chided, before moving on from him to the next patient. 

“Don’t worry. I understand how it is. Just improve next time, okay?”, the consultant reassured.

What we have just witnessed here, is a phenomenon that regularly occurs in Medical Institutions across the country and the world. Threats, intimidations, and hollering is commonly encountered in medical colleges, government hospitals and private hospitals, and this occurs specially from a senior medical practitioner to a junior doctor. 

It takes close to 10 to 14 years to be an experienced licensed medical practitioner ^1,2. The long hours of study, combined with the uncertainty of not being able to easily pick a stream that the junior doctor would practice for the rest of their life, places a lot of burden on the doctor once he or she finishes the undergraduate medical school. 

Dr. Janelle Luk, in a report by usnew.com ² mentioned that most med students were in their 20s and 30s, which made it difficult for these students to see their same-aged peers settling down and starting families while they often had anxieties about falling behind on their relationship and family goals. This situation is quite accurate to the Indian scenario where Indian medical students undergo a similar process. 

This leads the older generation of doctors to believe that they worked much harder under difficult circumstances as compared to the millennial generation or the generation Z. For example Baby boomer Robert Centor, MD, MACP, who first worked as an attending consultant on January 1980, before today’s millennials were born, said that the older generation were of the opinion that the youth were overprivileged and not as dedicated. ³ This can be corroborated with any senior doctor working here. 

This perception amongst the senior doctors, combined with the stressors they faced during their training is all pervasive, contributing to their irate behaviour against the junior doctors. Medical doctors are also prone to bursts of anger, often with regards to the patient, or to the behaviour or actions of a junior doctor, which may or may not be well founded. 

Doctors, nurses, and other Health Care Practitioners often face difficult, frustrating, and stressful conditions ⁴. Long working hours and poor work life balance give the doctors little time to reflect, to acknowledge and work on their anger and transform their emotions into healthy communication styles. 

And it is this unprocessed anger that the senior doctor offloads to a junior doctor, which then the junior doctor emulates to carry forward to the next generation. This is often not talked about, and is seen as the rite of passage amongst medical professionals the world over. The concept of:

“Since I have been through so much difficulty during my formative years, my junior should undergo the same, and this is good for his or her character!” takes birth. With very few taking stock of the situation to figure out what is wrong.

This brings us to understanding the term ‘Transgenerational Trauma’. 

What is Transgenerational Trauma?  Transgenerational trauma is also referred to as ‘intergenerational trauma’, or ‘generational trauma’ refers to how trauma passes through generations. A new field of research, which started in the 2000s, refers to the idea that trauma is passed on behaviourally and biologically. Which means that not only can someone experience trauma, they can then pass the symptoms and behaviours of trauma survival on to their children, who then might in turn pass these further along the family line, to the grandchildren and so on. ⁵

Intergenerational trauma can manifest as lack of trust of others, Anger, Irritability, Nightmares, Fearfulness and the Inability to connect with others. ¹⁹

With the ongoing generations of doctors that work together in medical institutions, this transgenerational trauma becomes apparent with the data as highlighted below. 

Psychological Trauma is prevalent amongst Medical Professionals and healthcare workers. McManus et al. (2006) found that the person who took up a medical career had a correlation with their personality type. Persons who chose medicine to help others were more agreeable and had higher scores in empathy. ⁶
It is no surprise that empaths and sensitive people often experience some level of post-traumatic stress. This is, in part, because of the sensory overload they are exposed to for so many years that their systems are flooded with adrenaline. ⁷

In a recent report by The Hindu, in April 2023 mentions, that a recent Right to Information (RTI) response from the National Medical Commission (NMC), 64 MBBS and 55 postgraduate medicos died by suicide in the last five years. This was in addition to 1,166 students who dropped out of medical colleges of which 160 were studying MBBS and 1,006 pursued postgraduate courses. ⁸ 

The report found that mental ill-health was the next most common reason in medical students (24%) and physicians (20%) after academic stress and marital discord, while harassment (20.5%) was a cause for residents. Upto 26% had exhibited suicide warning signs and only 13% had sought psychiatric help before ending their lives. ⁸

What better evidence of psychological trauma do we have as compared to these statistics mentioned above?

13% is a miniscule number. And this projected onto the vast majority of the practicing doctors, how likely is a distraught, short tempered senior medical professional likely to seek psychological help before displaying his anger towards a junior doctor?

Communication, is the cornerstone of the effective running of any organization. However, this communication is not always seamless amongst medical professionals. Extensive review of  literature showed that communication, collaboration, and teamwork did not always occur in clinical settings. In a study by Sutcliff, Lewton, and Rosenthal ⁹ revealed that social, relational, and organizational structures contributed to communication failures and were implicated to contribute largely to adverse clinical events and outcomes.

Over the recent years much original research has been conducted on the impact of physician disruptive behaviors (defined as any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment) and its effect on staff relationships, staff satisfaction and turnover, and patient outcomes of care. 

The effects of the above would influence patient related adverse events, medical errors, compromises in patient safety, poor quality care, and links to preventable patient mortality. Many of these undesirable effects could be traced back to poor communication and collaboration, and ineffective teamwork. ¹⁰

A review literature showed that a common barrier to effective communication and collaboration was hierarchies. ^11-15 A study by Sutcliff and colleagues’ research ¹⁶ concluded that communication failures in the medical setting arose from vertical hierarchical differences, role conflict, and ambiguity and struggles with interpersonal power and conflict. Communication was likely to be distorted or withheld in situations where there were hierarchical differences between two communicators, particularly when one person was concerned about appearing incompetent, and did not want to offend the other, or perceived that the other was not open to communication.

All of the above reasons contribute towards the psychological trauma meted out to junior doctors, and hence perpetuates the unsafe work atmosphere. This translates to poor patient outcome and increased attrition of medical professionals in the organization. ¹⁷

It is therefore, of vital importance that this unreasonable anger by senior medical professionals is addressed and mitigated before it passes on to successive generations of doctors and healthcare professionals. 

This is why it is critical that the senior medical professionals do their Inner Work. By looking inward, they can become more aware of their own triggers and how their experiences influences their behaviour towards the junior doctors. ¹⁸

Methods to mitigate the effects of transgenerational trauma can be to share what one is burdened by. To begin healing, the senior medical professional needs to know the extent of past issues. Once identified, he or she can begin to see the impact of the trauma. Anger, sadness, anxiety, and substance use could all arise out of trauma. Working as a team could help improve the health of the department and the organization instead of pointing fingers at one another. It is important that they learn how to change habits rather than carry forward the cycle of abuse. The thoughts, feeling and behaviour from trauma must be ended. Apart from all of these behavioural changes, it is of vital importance that the medical practitioner seeks professional help from a clinical psychologist or psychiatrist to help in the healing process. ¹⁹

The above measures would contribute to a safe workplace and direct a better outcome for patients as well as the healthcare worker.

References:

1. https://www.indeed.com/career-advice/finding-a-job/how-long-does-it-take-to-become-a-doctor
2. https://www.usnews.com/education/best-graduate-schools/top-medical-schools/articles/2018-12-13/how-long-is-medical-school-and-what-is-it-like
3. https://acpinternist.org/archives/2016/10/millennials.htm
4. https://www.psychiatrictimes.com/view/anger-among-health-care-professionals
5. https://www.harleytherapy.co.uk/counselling/what-is-transgenerational-trauma.htm
6. Irina Crumpei, Ion Dafinoiu, Secondary Traumatic Stress in Medical Students, Procedia – Social and Behavioral Sciences, Volume 46, 2012, Pages 1465-1469, ISSN 1877-0428, https://doi.org/10.1016/j.sbspro.2012.05.322.

7. https://www.psychologytoday.com/us/blog/the-empaths-survival-guide/202006/7-ways-empaths-can-heal-trauma-and-ptsd
8. https://www.thehindu.com/news/national/india-lost-119-medical-students-to-alleged-suicide-over-five-years/article66691853.ece#:~:text=According%20to%20a%20study%2C%20358,intervention%20from%20students%20and%20parents
9. Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186–194
10. O’Daniel M, Rosenstein AH. Professional Communication and Team Collaboration. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 33. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2637/
11. Dansereau F, Markham SE. Superior-subordinate communication: multiple levels of analysis. In: Jablin FM, Putnam LL, Roberts KH, et al., editors. Handbook of organizational communication. Newbury Park, CA: Sage; 1987. pp. 343–88.
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13. Jablin FM. Task Force relationships: a life-span perspective. In: Knapp ML, Miller GR, editors. Handbook of interpersonal communication. Newbury Park, CA: Sage; 1987. pp. 389–420.
14. Jablin FM. Task/work relationships: a life-span perspective. In: Jablin FM, Putnam LL, Roberts KH, et al., editors. Handbook of organizational communication. Newbury Park, CA: Sage; 1987. pp. 389–420.
15. Stohl C, Redding WC. Messages and message exchange processes. In: Jablin FM, Putnam LL, Roberts KH, et al., editors. Handbook of organizational communication. Newbury Park, CA: Sage; 1987. pp. 451–502.
16. Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186–194
17. https://kredily.com/hrm/reasons-behind-employee-attrition/
18. https://www.betterup.com/blog/transgenerational-trauma