As a disaster mental health (DMH) professional, I have responded to five mass public shootings since 2017 and have had the opportunity to provide support to hospitalized survivors as well as their loved ones. I’ve stood in emergency departments and intensive care units in Uvalde, Texas, Las Vegas, Nevada, and Lewiston, Maine. I have watched dedicated physicians work tirelessly to save the lives of fellow community members. I have heard stories of their heroism, and I have witnessed it with my own eyes. Yet, despite their significant role in the aftermath of these incidents, this group has been largely overlooked in academic literature, and their voices have often been excluded from discussions surrounding mass public shootings. In recent years, physicians have attempted to make their voices heard by tweeting photographs and stories about their experiences treating victims of gun violence using the hashtag “ThisIsOurLane,” a movement initiated by Brady Center to Prevent Gun Violence board chair and chief medical officer Dr. Joseph Sakran. Through these graphic images and narratives, it is clear that these healthcare professionals are profoundly impacted by what has been referred as a gun violence epidemic.

The Psychological Toll

Physicians are not immune to the physical and psychological effects of trauma. Due to the nature of their careers, these individuals often work long hours in high-pressure environments, frequently leading to exhaustion and burnout, particularly in emergency medicine (EM) settings. One recent study found that 15.8 percent of EM physicians and 29 percent of EM residents meet the criteria for posttraumatic stress disorder (PTSD). Additionally, up to 40 percent of trauma surgeons have posttraumatic stress symptoms (PTSS), with 15 percent meeting the full diagnostic criteria for PTSD. While these physicians frequently treat individuals affected by gun violence, when treating victims of mass public shootings, the prevalence of PTSS and PTSD among physicians may be even higher, as research suggests that exposure to human-made disasters can lead to increased levels of distress, especially considering the volume and severity of patient presentations. Furthermore, these physicians often live in the communities affected by these incidents, and some may even personally know the victims they are treating, especially in rural communities and smaller towns, potentially exacerbating their risk of experiencing both short- and long-term stress reactions. However, the needs of these medical professionals are frequently neglected during recovery efforts, and due to this, physicians have been considered unrecognized survivors of mass killings.

The needs of these medical professionals are frequently neglected during recovery efforts, and due to this, physicians have been considered unrecognized survivors of mass killings.

Recently, Dr. Craig Goolsby, Department Chair and Professor of Clinical Emergency Medicine at Harbor-UCLA, convened a group of emergency medical services (EMS) professionals, EM physicians, and surgeons who responded to six high-fatality mass shootings in the US. Their objective was to develop consensus recommendations for improving care and patient outcomes during these tragic incidents. Among their eight recommendations in the final report was the inclusion of tailored mental health services for all responders, whether present at the scene or the hospitals. While the experiences of other first responders, such as EMS, and other hospital personnel, like nurses, have been explored, less is known about physicians. Therefore, in collaboration with Dr. Goolsby, my research colleagues and I conducted a qualitative study using semi-structured individual interviews to explore the experiences and needs of physicians following mass public shootings. More specifically, our research centered on nine physicians in seven impacted communities. While a previous study examined the experiences and immediate needs of physicians working in hospitals located in communities impacted by mass public shootings, our study focused on the ongoing needs of these medical professionals across all disaster phases.

Our findings revealed that these incidents significantly affected most participants in the short term. Many shared how they initially compartmentalized their emotions and struggled to process what had happened. For instance, one participant shared, “it ended up being like, oh, wow, what was that about when I ‘woke up’ two days later…I remember getting home after another busy shift and just breaking down.” Participants also described how these incidents had lasting effects on their lives. One participant shared, “it’s life-changing…it will stay with me forever. It’s changed my career.” Some participants also experienced long-term impacts, including hypervigilance and avoidance of large crowds and gatherings. For instance, one participant stated, “I used to go to college football games all the time. I don’t think I’ve been to a college football game since.… I don’t want to be in crowds as much as I used to.” Another shared, “I had a very visceral reaction to discussions around it [the incident] for months, if not years. It has had huge effects.”

One participant shared, “it’s life-changing…it will stay with me forever. It’s changed my career.”

Stigma and Help-Seeking

Despite being profoundly impacted, most participants in our study did not seek formal mental health support. While many acknowledged that mental health support was made available to them following these incidents, these services were underutilized. Instead, many physicians preferred to engage in informal peer support, including peer mentorship and gatherings in relaxed settings, such as at the homes of fellow physicians.

Our interviews reflected that reluctance to seek formal mental health support might be due to the stigma physicians often face and the fear that licensing bodies may revoke or restrict their license to practice should a mental health issue be disclosed on a licensing application or renewal. For instance, one participant stated,

I strongly identify as an emergency physician….and that could be taken away from me if when I reapply for my medical licensure, they ask, ‘have you ever had any mental health disorders?’ If I get a diagnosis because I was having issues dealing with an event and I have to disclose that, I’m placing myself in jeopardy of losing my medical license.

Another shared, “if you go and seek help and receive that diagnosis, you will have to notify the [state] medical board. You could be in danger of losing your license, so there is not only a stigma, but there’s negative reinforcement.”

Stigma related to help-seeking is not unique to physicians who treat casualties of mass public shootings, as this issue has been discussed extensively for many years. However, the demand for mental health support and tailored services is likely even greater during and after human-made disasters, such as mass public shootings. Therefore, efforts should be made to alleviate barriers to accessing support to improve overall well-being, decrease burnout, and better equip physicians to respond during these and other trauma-related incidents. Creating a culture of care and taking proactive measures to promote wellness among physicians is imperative, as “an ounce of prevention is worth a pound of cure.”

Overcoming Barriers

Physicians face complex challenges and barriers when attempting to access mental health support. While the disclosure of mental health diagnoses to medical boards was initially intended to safeguard the public from physicians who may be impaired, the Federation of State Medical Boards (FSMB) contends that such disclosure does not reliably predict the risk of harm to patients. Instead, it prevents physicians from receiving necessary mental healthcare, potentially exacerbating impairment. To help mitigate these barriers, the FSMB offered several recommendations, including urging medical boards to “evaluate whether it is necessary to include probing questions about a physician applicant’s mental health, addiction, or substance use” on licensure applications or renewals. More specifically, the FSMB made the following recommendations to be compliant with the Americans with Disabilities Act (ADA): (1) limiting mental health questions to conditions that result in impairment; (2) limiting mental health questions to conditions within the past two years or less; (3) not requiring physicians to disclose their diagnosis or treatment to the board if they are enrolled in a Physician Health Program; and (4) using supportive language about seeking mental health care. However, a recent study found that only 5 percent of medical boards were in compliance with the FSMB’s recommendations.

Access to supportive services is vital, as burnout and poor mental health among physicians have been linked to increased rates of suicide, as well as medical errors and suboptimal patient care. Therefore, to eliminate barriers to help-seeking, state licensing boards might carefully consider revising their policies to align with the recommendations put forth by the FSMB. For example, in 2020, the Texas Medical Board (TMB) revised the language related to mental health in applications for initial medical licenses and renewals. Due to these changes, the TMB is now in full compliance with the FSMB’s guidelines, fostering a more supportive atmosphere and reducing obstacles to mental healthcare. Furthermore, because mental health support is underutilized by physicians, alternative forms of support should be made available to them following mass public shootings. Facilitating opportunities for peer support, for instance, can be a valuable resource, as this can help normalize emotions and reactions to difficult experiences and has been found to increase well-being and reduce mental health stigma among physicians. To enhance support, hospitals might consider organizing formal and informal gatherings for these individuals to come together and begin to process.

Additionally, physicians should be afforded ample space and time to decompress and grieve. In our study, five participants mentioned the challenges of dealing with the media coverage in the immediate aftermath of the incident and how they did not have an opportunity to reflect on or process their emotions before they were required to make a statement to the press, as has been seen in several post-incident news briefings in the past. Due to this, hospitals should allow physicians to decline requests for press interviews and consider designating a hospital spokesperson who is uninvolved in the medical treatment of casualties to handle any media requests.

Community support also plays a crucial role in the recovery process for physicians after mass public shootings. Hospital systems can partner with local and regional healthcare networks to facilitate shift coverage and adequate time off so that these individuals can participate in community memorials and vigils. Attending public rituals can promote community solidarity and cohesion, bolstering resilience in those affected by disasters. Additionally, hospitals should recognize the lasting effects mass public shooting incidents can have on physicians, providing tailored support and adopting a trauma-informed approach and policies across all stages of disaster recovery. Some participants, for example, expressed the desire to give back to their communities and the medical profession and found channeling their grief into action to be an important part of their recovery journey. One participant shared, “I had to figure out how I was going to make something better of this.” However, not all felt supported by their employers in pursuing these endeavors. Hospital systems should acknowledge the diverse ways in which meaning-making and healing occur and support physicians in these activities, as altruism has been found to foster post-traumatic growth.

Physicians are often overlooked following mass public shootings and may ultimately suffer in silence. These medical professionals should be offered equal opportunities to heal alongside others within their communities, as “no one who sees a disaster is untouched by it.” Ultimately, the mental health and well-being of physicians should be prioritized and help-seeking normalized after mass public shooting incidents. Additionally, while this piece highlights the needs of physicians, it is important to acknowledge that other members of the broader healthcare team, like respiratory therapists, hospital technicians, and social workers, are also often overlooked. Therefore, further studies are warranted to understand their experiences after mass public shootings. Ultimately, it is time to heed the call to care for those who selflessly care for us.

ABOUT THE AUTHOR

Rebecca Cowan is a faculty member in the College of Social and Behavioral Health at Walden University and an affiliate scholar with the Regional Gun Violence Research Consortium. As a disaster mental health supervisor with the American Red Cross, she has responded to several mass shootings, including the Route 91 Harvest Festival in Las Vegas, Nevada, Marjory Stoneman Douglas High School in Parkland, Florida, and Robb Elementary School in Uvalde, Texas. Cowan also served as a gubernatorial appointee on the Commission to Investigate the May 31, 2019, Virginia Beach Mass Shooting.