There is an emerging recognition that the Covid-19 pandemic was “gasoline” on the existing “fire” of professional burnout in both frontline and supporting health caregivers, including first responders. The need for the skills to both heal burnout and build resilience is greater than ever.

Physician burnout and suicide is not a new phenomenon. Marchalik1 noted that the 1226 physicians who attended anatomy lectures at St. Bartholomew’s Hospital in London, UK between 1839 and 1859 had a suicide rate 25 times higher than the average male suicide rate during that period of time. Hubbard 2 in 1922 noted that the suicide rate of physicians was more than double the next highest profession. Hubbard concluded that the “occupational strain in medicine is greater than in any of the other professions.”2 (p. 857). Physician burnout has also been reported in other countries with significantly different systemic and cultural factors.3 4

In our experience a significant but generally unrecognized factor in burnout is the role of secondary trauma. While the concept of secondary trauma in health care has been recognized,5,6,7, there is not a clearly defined understanding of how this occurs. Our hypothesis is that “secondary trauma” is mediated by a relatively recent discovery: the “mirror neuron” system in the human brain.8

The mirror neuron system, discovered in humans in 2000, in which motor neuron, emotions and intention are “mirrored” in the brain of an observer, is believed to be the neurological basis for empathy.9 In 2006, Dapretto observed that children with autism had significant lack of mirror neuron activity, and this correlated with the social deficits associated with a lack of understanding of emotions in others.10 Our hypothesis is that individuals on the higher end of the normal distribution curve for mirror neuron system development are more likely to have innately high levels of empathy. These empathic individuals are more likely to experience the pain, both physical and emotional, of their patients, families and co-workers as a consequence of their increased sensitivity. In the absence of specific training, most physicians use emotional suppression in an attempt to manage their own negative emotional responses. Paradoxically, emotional suppression actually promotes numbness, depression and leads to burnout.11


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  2. Hubbard DS. Suicide Among Physicians. Am J Public Health. 1922;12(10):857-857. doi:10.2105/ajph.12.10.857-a
  3. Ziad K, Laurent B, Marianne H, Villes V, Christophe L, Guillaume F. Burnout in French physicians: a systematic review and Meta-analysis. J Affect Disorders. 2018;246
  4. Lee JF, Stewart M, Brown J. Stress, burnout, and strategies for reducing them: what’s the situation among Canadian family physicians? Can Fam Physician Médecin De Fam Can. 2008;54(2):234-235
  5. O’Mahony S, Gerhart JI, Grosse J, Abrams I, Levy MM. Posttraumatic stress symptoms in palliative care professionals seeking mindfulness training: Prevalence and vulnerability. Palliative Med. 2016;30(2):189-192. doi:10.1177/0269216315596459
  6. Schiff J, Lane AM. PTSD Symptoms, Vicarious Traumatization, and Burnout in Front Line Workers in the Homeless Sector. Community Ment Hlt J. 2019;55(3):454-462. doi:10.1007/s10597-018-00364-7
  7. Mealer M, Burnham EL, Goode CJ, Rothbaum B, Moss M. The prevalence and impact of post traumatic stress disorder and burnout syndrome in nurses. Depress Anxiety. 2009;26(12):1118-1126. doi:10.1002/da.20631
  8. Umilta, M.A., Kohler, E., Gailese, V., Fogassi, l., Fadiga, L. I Know What You Are Doing: A Neurophysiological Study. Neuron. 2001;31(1):155-165.
  9. Carr, L, Iacobini, M, Dubeau, MC ,Mazziota, JC, Lenzi, ll. Neural Mechanisms of empathy in humans: A relay from neural systems for imitation to limbic areas. Proceedings of the National Academy of Sciences, 2003, doi/10.1073/pnas.0935845100
  10. Dapretto M, Davies MS, Pfeifer JH, et al. Understanding emotions in others: mirror neuron dysfunction in children with autism spectrum disorders. Nat Neurosci. 2005;9(1):28-30. doi:10.1038/nn1611
  11. Gross, J.J., Handbook of Emotional Regulation. (2nd ed.) 2014. Guilford Press, New York, N.Y. ISBN 978-4625-0350-6