Bearing Witness: Vicarious Trauma in Family Medicine
Note: Patient and family details have been modified to protect confidentiality.
When I walked into the room, she and her father were looking through old photos together. The old glossy kind that were kept in treasured boxes. He was more present that day, despite the scabs and small areas of dried blood on his face, and the bruises still peeking out from beneath his hospital gown. She was doing her best to hold it together.
We talked about his condition, what would be best moving forward. He had stage 4 cancer and had been on the verge of hospice when a traumatic fall brought him to us. He was stubborn, still fighting to hold onto his independence. The kind of stubbornness I recognized in my own father once at an earlier time in our lives.
Now the conversation we’d been circling had to happen.
He was being transferred back to his in-network hospital, now more stable, with goals of care clearly defined. Hospice. She looked at me with tired eyes and asked me what I would do if it were my father.
I told her.
She was reassured, and said, “I don’t know how you do it, doc.”
It was that kind of week.
In medicine, we sometimes joke about themed weeks. Some weeks we see patient after patient with GI bleeds. Other weeks it’s cirrhosis, or sepsis, or strokes. This particular week had a theme none of us chose: hospice. Multiple patients transitioned to comfort care within a week. Multiple families navigating the hardest conversations of their lives. Multiple moments of sitting at the bedside, bearing witness to grief in real time.
For whatever reason, this patient stuck out to me. Maybe it was the state he arrived in. Maybe it was the loyalty he commanded of his friends and loved ones despite his personal struggles with substance use. The way people kept showing up for him told a story of a man who loved deeply and was deeply loved in return, flaws and all.
Whatever the reason, this case felt personal to me.
Maybe because I had been in that daughter’s position not too long ago. When the conversation turned to hospice, I understood what she was carrying. The weight of trying to make the right call for someone who raised you and loved you so deeply.
And she wasn’t the only one who said those words to me that week.
“I don’t know how you do it.”
Multiple families. Same phrase. Same week.
Which made me wonder: how do we do it? And at what cost?
Vicarious trauma is the cumulative emotional impact of repeated exposure to patients’ suffering and loss. Over time, that exposure disrupts our deeply held beliefs about safety, trust, and justice in the world. It seeps into how we parent, how we relate to our partners, how we move through everyday life. And if left unaddressed, research suggests it can progress to PTSD. In 2013, the DSM-5 added “repeated or extreme indirect exposure to aversive details of a traumatic event”, such as that experienced by a first responders or police, as a qualifying stressor for diagnosis. This is not a coincidence, and is recognition that what we witness at work carries real psychological weight.
As family physicians, we are particularly vulnerable. We see patients across the full spectrum of human experience: domestic violence, cancer, addiction, grief, end of life. Certain factors increase our risk further, including a personal history of trauma, limited social support, negative coping behaviors, and working with patient populations who carry disproportionate trauma burdens.
Sound familiar? Many of us check more than one of those boxes.
Over time, the weight accumulates. Vicarious trauma can manifest as what trauma-informed clinicians recognize as the four trauma responses: fight, which can look like irritability or outbursts with colleagues or at a meeting; flight, which can look like avoiding difficult patient conversations or calling in sick at the last minute; freeze, which can look like emotional numbing; and fawn, which can look like over-accommodating patients and families at the expense of our own boundaries. If left unaddressed, research suggests these responses can deepen and progress to PTSD. It can also show up more quietly, like a colleague who becomes uncharacteristically short with staff.
We’ve all seen that person. Some of us have been that person.
What I find interesting is that none of this was ever part of our training. We were taught to diagnose, to treat, to move efficiently from room to room. We were taught to compartmentalize, which is not necessarily a bad thing. It is what lets us walk into the next room and be fully present for the next patient. But compartmentalizing without ever processing is where it starts to cost us. The good news is that small, intentional practices can make a difference.
Over time, a few things have helped me stay intact through the hard weeks. Simply naming that “it’s been a really hard week” is more powerful than it sounds. We are so conditioned to push through that we skip the step of acknowledging what we just experienced. Saying it out loud, to yourself, even in the car on the way home, creates some distance. From there, creating a transition ritual can help process the feelings we are carrying between work and home. For some it’s as simple as taking off the white coat at the end of the day, a physical act of leaving the role behind. For others it’s a shower when they get home, washing off not just the day but the weight of it. For a long time, I would turn on loud music or a podcast the moment I got in the car. It took me a while to realize that was my way of avoiding the feelings I didn’t want to sit with. When I started allowing myself to just drive in silence, I found that I could process the day better instead of carrying it home.
There are many other ways of processing vicarious trauma. Journaling, getting the experience out of your head and onto paper, is one. A few minutes of intentional breathing or mindfulness can be another, just enough to notice where the tension is sitting in your body and begin to release its physical impact. Getting support by talking to a colleague or someone you trust is also part of it, as is seeking your own dedicated space through therapy or coaching. We refer our patients to mental health professionals without hesitation, so why not afford ourselves the same care and compassion? This is what allows us to continue showing up with presence, with our best selves, and to build sustainability in a career that costs us so much.
At the same time, this shouldn’t fall solely on individual physicians to figure out alone. Health care organizations have a role here too. Protecting physicians means recognizing the emotional weight of this work, intentionally creating space and time for processing, whether through monthly therapy or coaching sessions, limiting patient load, providing additional administrative and staffing support, and building systems that genuinely care for the people doing the caring.
Since then, I’ve thought a lot about what she said.
“I don’t know how you do it”.
The honest answer, the one I didn’t say, is that sometimes I don’t. Sometimes it follows me home and sits heavily on my chest. Other times it seeps through when I’m spending time with my own family. Sometimes a patient reminds me of my father, and I just have to sit with the feelings of grief and love that come with that.
But here’s what I’ve come to understand: in most rooms, it isn’t my medical knowledge that matters most. It’s my presence. My willingness to sit with a family in the uncertainty and say, you are doing what your loved one would have wanted. To offer the reassurance even when sometimes there’s no “right” thing to do in medicine. Not every case is a complex diagnostic mystery waiting to be solved, like something out of a House episode. Some of the hardest cases aren’t mysteries at all. They’re just life, unfolding in front of us whether we’re ready or not.
What our patients deserve is the willingness to stand beside them in those moments. To guide them with our knowledge, yes, but also to hold space for what can’t be fixed, diagnosed or charted. To bear witness, fully, humanly, imperfectly, to what is unfolding in front of us. And then, when we walk out of that room, to take seriously the weight we are carrying. To name it and process it. Because unprocessed vicarious trauma doesn’t just disappear. It accumulates and changes who we are as doctors. If we are not intentional about tending to it, it will quietly erode the very presence and compassion that make us amazing physicians in the first place.
That is the work we do as family physicians. It’s not easy, but I absolutely love what I do. And I’d choose to do this over and over again.
Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Exhibit 1.3-4, DSM-5 Diagnostic Criteria for PTSD. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207191/box/part1_ch3.box16/
Ravi A, Gorelick J, Pal H. Identifying and Addressing Vicarious Trauma. Am Fam Physician. 2021;103(9):570-572.
Quitangon G. Vicarious Trauma in Clinicians: Fostering Resilience and Preventing Burnout. Psychiatric Times. 2019;36(7).
