Let me introduce you to Maya and her husband, Dr. Steven. While Maya and Dr. Steven are a hypothetical couple, their story reflects the lived experience of many of the physicians and their spouses I’ve had the privilege of sitting across from in my office over the years. Maya and Dr. Steven’s story isn’t remarkable because it’s unique. It’s remarkable because it isn’t. Working with physicians and their spouses over the years, I’ve heard versions of this same story more times than I can count. The names and details change, but the storyline remains the same.

As the veteran spouse of a physician, Maya remembered the earliest window she had into her husband’s struggles was during his residency. At social gatherings, she used to take some offense at the way her husband and the rest of the residents would seek each other out to the exclusion of everyone else. There was something that stung watching her partner walk into a room full of people and really only be able to land when he found another resident, pulled together into their own small universe. It was hard not to feel left out as Dr. Steven peeled himself away from her and beelined to the only conversation that seemed to matter.

Years later, Maya knows now what she didn’t know then. The residents were desperately clinging to one another, like swimmers caught in a riptide being pulled out to sea, far from the safety of the ‘shore’ they thought good medicine would be. They were looking for validation, confirmation that they weren’t the only ones experiencing this, whatever this happened to be for each of them at that moment. 

What Maya interpreted as rejection was actually Dr. Steven looking for something closer to rescue. Those clusters of residents weren’t shutting the world out; they were holding one another up.

They were asking, Are you okay? Because I’m not sure I am.

The quiet unraveling of everything they thought they knew about themselves and medicine was not unique to them. There was nothing wrong with them. They were just struggling to swim against the current and needed someone who knew how it felt to be in the water with them.

The this they were processing was a combination of chronic stress, little “t” trauma, and big “T” trauma. No one warned them it would be the water they would find themselves swimming in as physicians.

Chronic Stress

Chronic stress is not a single event; it’s the slow, relentless accumulation of demands that persistently exceed an individual’s capacity to meet them.  It is the prolonged activation of the body’s stress response system, originally designed for short bursts of intense activation to ensure survival, that is instead perpetually locked in a state of being always on. 

The stress response is a remarkable cascade of events designed to mobilize us in moments of physical danger. The problem is that it didn’t evolve to manage threats that can’t be outrun, yet it is activated by them anyway. It wasn’t designed to help physicians navigate hospital administrations, insurance denials or documentation that follows them home.

The signal that the danger has passed never comes, leaving the body perpetually in a state of activation. The cost of that quietly accumulates and, over time, this sustained state of physiological arousal impacts sleep, immunity, cognition, emotional regulation, and relationships. Unlike acute stress, chronic stress has no finish line. 

Dr. Steven’s chronic stress looked like the cumulative weight of a schedule that barely allowed for quick restroom breaks, let alone meals, documentation that followed him home every night, the low-grade hum of always being behind at work, and never quite feeling like he was enough at home either.

Little “t” Trauma

Little “t” trauma refers to distressing experiences that, while not life-threatening, are significant enough to overwhelm an individual’s ability to cope and leave a lasting emotional imprint. These can be one-off or repeated events that rise above the level of chronic stress. Coined within the framework of modern trauma theory, little “t” traumas are often dismissed precisely because they don’t look dramatic enough to “count,” which is, ironically, a large part of what makes them so insidious and vulnerable to talk about out of fear of judgment.

The cumulative effect of multiple little “t” traumas can be just as psychologically impactful as a single catastrophic event, particularly when they occur in environments where emotional processing is discouraged.

For Dr. Steven, this markedly happened during his fourth year of med school when an attending pounced upon his eager naïveté and eviscerated him in front of a room full of residents. Not life-threatening, but a moment that quietly rewired something in Dr. Steven. The number of little “t” traumas Dr. Steven has experienced since then is too numerous to count, but the one he feels the most vulnerable about sharing was a very bad Google review from a patient he tried to do right by.

Little “t” trauma is particularly insidious in medicine because the environment in which it occurs pathologically normalizes it and prevents it from being processed or openly spoken of.

Big “T” Trauma

Big “T” trauma, as defined by the Diagnostic and Statistical Manual of Mental Disorders, involves direct exposure to actual or threatened death, serious injury, or sexual violence experiences so acutely overwhelming that they shatter a person’s fundamental sense of safety. 

As a therapist, I will tell you that this definition fails to include many of the potential causes of big “T” trauma, which all result in the same symptomatology. Any significant event that the nervous system was never designed to process regularly is far more accurate and inclusive.

Our brains take their primary job of keeping us alive very seriously. They create complex schemas, working models, for how the world works, so that we can anticipate what is likely to happen next and plan. Plan, act on those plans, and bask in the glow of being right. But there are times when, despite years of fine-tuning and confirmation, the model(s) fail.

On any given day, a schema can be so, very, very wrong that the whole thing comes crashing down. Things like the death of a child, a spouse’s affair, being sued for malpractice by a patient who received good care, or a car accident. Any number of horrific things can happen without warning, to good people, causing their brains to get stuck in the wreckage of what had been, up until then, a reliable working model.

Big “T” trauma leaves us sitting in the rubble of our old schema, unable to move forward because we can’t get past what happened, how we did not see it coming, and whether or not we can trust our brain to build a new schema going forward.

When the brain, unable to file the experience away and move on, gets permanently stuck at the scene of the Big “T” trauma, flashbacks, hypervigilance, nightmares, and the exhausting work of avoiding anything triggering become the new normal. 

The genuinely hopeful news, and I cannot emphasize this enough as a therapist that treats trauma, is that the same brain that chronic stress and trauma have quietly shaped over the years is also capable of amazing post-traumatic growth. The therapeutic tools available are effective. 

Treatment of stress and trauma falls into two broad categories: top-down approaches like Cognitive Behavioral Therapy that target how we think about the stress or trauma, and bottom-up approaches that directly target the stress or trauma memory itself, like Accelerated Resolution Therapy (ART), a newer iteration in the family of EMDR. ART is a particularly compelling option for physicians because it typically requires fewer than 5 sessions, is evidence-based, and does not require talking about the trauma. 

There is a shore, and there are very good people, with very good tools, who know how to help get their clients back on solid ground.

What You Can Do Right Now

1. Call it what it is. The single most powerful thing you can do for yourself and your colleagues is to call it what it is. Chronic stress, little “t” trauma, and big “T” trauma each require different responses and are attributable to external factors; something bad happened.

2. Get back to the basics. You would never tell a patient that sleep, good nutrition, exercise, or meaningful interaction with those important to them are optional. These are the foundational coping skills that all the rest are built upon. Then, lean into other healthy coping skills that have worked in the past. Focus on what is in your circle of control and expend energy there.

3. Lower your threshold for seeking professional support. If you would encourage a friend or a family member presenting with your symptoms to seek professional support, you owe yourself the same care.