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As a critical care physician, Kelli Mathew knew her days were spinning in the wrong direction. For one thing, her well of empathy was dry. When unvaccinated people came to her, suffering the effects of COVID, Mathew began snapping back. She had run out of comforting or even neutral things to say.

“In my mind, it was like, ‘This is your doing. You chose not to get vaccinated and here you are,’” says Mathew, who works at Deaconess Henderson Hospital in Henderson, Ky. “I would say, ‘You’re probably going to die and this could have been preventable—how sad is that?’ I would walk away. And that’s not who I am.”

In the end, Mathew reached out for help, entering counseling to try to understand what had happened. Her doctor-patient relationships were crumbling in front of her, and she knew she was the reason why. “I’ve always been the most empathetic, compassionate person to a fault,” she says. Clearly, something had changed.

For nearly 18 months, critical care workers have been on the front lines of one of the worst medical crises in American history. The intensive care unit (ICU) death toll for COVID-19 patients is almost unimaginable: a mortality rate of approximately 35 percent, according to one meta-analysis. Nurses in the ICU have served, suffered devastating loss and ultimately left the profession in droves. We have read their stories of grief and pain.

Only now, in the long tail of COVID’s run, are we beginning to understand the depth of the toll the pandemic has taken on the physicians on the front lines. Although hardly surprising, the news is not good.

“ICU doctors are experiencing among the highest levels of stress, burnout and fatigue from COVID-19, says Greg Martin, president of the Society of Critical Care Medicine. “Perhaps more than any other specialty, they continue to experience the full brunt of COVID-19.”

Over the past few weeks, I’ve had conversations with many intensivists, mental health counselors and other health experts. The agreement is nearly unanimous: COVID is devastating some of ourcritical care physicians.

In a recent national survey of roughly 12,000 doctors, more than half of critical care physicians reported burnout. Staffing and personal protective equipment (PPE) shortages, the death toll, personal safety concerns, a feeling of inadequacy in providing emotional support to patients and their families—all contribute to a wave of difficulty that, deep into the summer of 2021, continues to build. The current surge in cases across the U.S. and the emergence of the Delta variant virtually assure that these scenarios will repeat, as ICUs again fill and, in some places, push beyond their normal capacities. “It really is a retraumatization,” says James Jackson, a leading authority on depression and post-traumatic stress disorder at Vanderbilt University Medical Center.

“I have seen many ICU physicians with somewhat uncharacteristic outbursts, apathy and sloppiness in patient care that I haven’t seen before,” says Gabe Wardi, a critical care specialist with the University of California, San Diego and two smaller facilities. “I think as doctors, and ICU doctors in particular, we pride ourselves on being able to handle any task or patient load. COVID was a reminder that we need to lean on others for our own mental health and patient care.” Wardi struggled with the fear of carrying infection home to his pregnant wife and young child, and he felt guilt over the amount of time he was spending at the hospital. His medical school roommate, he says, only recently returned to work after a year away, driven from his job by the trauma of seeing so many COVID patients die in his ICU.

Neil Greenberg, lead author of a U.K. study and professor at King’s College London, says that among those surveyed, ICU physicians confirmed “very high levels of post-traumatic stress symptoms, depression [and] anxiety, and some were also at risk of alcohol misuse.” More than one in seven ICU staff reported thoughts of suicide or self-harm. (In the U.S., an estimated 300 to 400 physicians commit suicide each year, roughly double the rate of the general population.)

Experts say that from the outset of the pandemic, physicians have had to deal with vast amounts of uncertainty, which pierces their normal sense of control and level of assuredness about their practice. As a 25-year emergency department physician, I can attest to that craving for control of medical outcomes, along with a tendency toward perfectionism. We want to do our best by our patients. COVID, though, has resisted such certainty. “It’s hit or miss,” says Mathew. “Some people live and some people die, and you can’t pick and choose.”

For some professionals in critical care, part of the frustration is the notion that the worst of the damage is largely avoidable. In Kentucky’s Henderson County, where Mathew works, only 36 percent of residents are fully vaccinated, along with about half the nurses at Deaconess (although the hospital will soon be requiring vaccinations of employees.) “We’re in the red zone,” she says. “It’s awful. I have a full ICU with only one code bed available.”

Mona Masood runs the Physician Support Line; since the spring of 2020, volunteer psychiatrists have fielded more than 3,000 calls from physicians anonymously requesting mental health support. In the pandemic’s early months, Masood says, ICU doctors were “up a creek without a paddle—that is, just doing whatever they could in order to survive.” Among other things, the line’s psychiatristsreceived calls about unprocessed grief, with some doctors saying they hadn’t had time to work through losing, say, 20 patients in the course of a single week.

“The psychological toll has been immense and is ongoing,” says Venktesh Ramnath, an ICU physician with UC San Diego Health. “Many health care workers are still trying to process and heal from the experiences of the last year, and there are harbingers of a fourth wave in which there is fear that earlier experiences and mistakes may be repeated.”

Physicians, especially intensivists, are trained to react in the moment and to push off emotional considerations for later. In the age of COVID, with its seemingly relentless waves of illness and death, that has proved impossible, in part because “later” never seems to arrive.

Erin Hall, a clinical health psychologist who has worked closely with the ICU teams at Geisinger Medical Center in Danville, Pa., has witnessed the trauma experienced by providers, often because obstacles beyond their control prevent them from delivering what they deem to be appropriate care. “Watching people die without family, with a stranger (usually a nurse) in the room just so the person was not alone—over time, this stuff does affect you,” Hall says. “You can be the most resilient person and still struggle with taking some of this stuff home.”

Mental health professionalsare quick to separate terms. Burnout is certainly common, but for ICU clinicians and other health care staff it is now increasingly being joined by moral injury, a sense that they’re not able to provide the care they normally expect to.

Morally challenging decisions, like rationing care because of resource shortages, have placed mental and emotional strain on ICU physicians. “There were a number of young patients who died that would have had at least a fighting chance with ECMO [an oxygenation machine],” says Wardi. But that was not possible at some smaller, community-based facilities, and patient transfers were impeded by overcrowding at  hospitals.

Physicians also are asked to deliver bad news to families, systemic barriers notwithstanding. They carry the sadness, blame and grief that’s often directed at them from patients. Masood says the resulting thought for some doctors is, “’Maybe I am the one who messed this up. Maybe I am the one at fault.” She describes this process as “death by a thousand paper cuts” for physicians’ psyches.

There is a practical health care aspect to this trauma. America faced a shortage of intensivists before the pandemic, especially in remote areas. Patricia Pittman, who runs the County Workforce Estimator, which tracks hospital labor deficits, says 198 counties in the U.S. are experiencing such shortfalls, requiring “crisis” levels of staffing. The pandemic “has exacerbated the issue,” says Martin. In an international survey of 2,700 ICU providers worldwide, the reported shortage of intensivists in the U.S. was put at 12 percent.

We had a dysfunctional health care system in the U.S. well before the pandemic, but with COVID the dike has broken wide open. The problems have been laid bare: inadequate staffing, inefficiencies, rising expenditures and the corporatization of medicine (with its ever-escalating productivity asks, documentation requirements and relative value unit, or RVU, and metric expectations). All these factors are combining to depersonalize medicine and suck the soul out of many providers.

Change is needed now, not later, and my conversations produced several suggestions from experts. Making mental health resourcesmore openly available to physicians is a must. Efforts to eliminate the stigma associated with doctors seeking help or admitting they are hurting—and, particularly, to remove mental health questions from state and hospital licensure applications—will open doors forall physicians to access much needed care.

We need health care leaders willing to be vulnerable and open up about their own struggles—affirming that they are indeed anxious, taking antidepressants, seeing a therapist, etc. These actions will help normalize the experience, giving other providers permission to be vulnerable, too. “Suddenly, we have all taken off our masks and communicated at a deeper level,” says Jackson.

And dealing with the structural problems—hospital dysfunction, staffing shortages and failed leadership, to name a few—is critical. A Mayo Clinic study determined that the most effective strategies for alleviating physician burnout “will target organization-directed changes rather than the level of the individual,” and that suggests the kind of broad-scale change the health industry often resists.

“It may be the question of the year for health care,” says Martin. “How do we really support providers? Because it gets to the question of why are people leaving the profession—and clearly they are.”

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