One of Us

By Sharon Tregaskis. Illustration by Alyssa Carvara.

Lorna Breen, MD, was just six months shy of her 50th birthday when she died on April 26, 2020, but the family and coworkers left to mourn her death are doing what they can to make sure her legacy reaches beyond how she spent those 50 years of life. 

Dr. Breen, VP&S assistant professor of emergency medicine, served as site director at the NewYork-Presbyterian Allen Hospital emergency department, learned medical Spanish to better serve her northern Manhattan patients, chaired the American College of Emergency Physicians’ work group that created a point-of-care tool for supporting patients with autism, and traveled to India to teach CPR. From her Converse sneakers to her brown pixie cut, she exuded confidence; her broad smile was legendary. Dr. Breen embraced opportunities to mentor and support junior colleagues and trainees; her scholarly research sought practical interventions to promote well-being and protect her team against the burnout endemic among emergency physicians. And at the time of her death, Dr. Breen was enrolled in an MBA-MS program in pursuit of her dream to work as a chief medical officer. 

“Lorna brought a passion, a dedication, an interest in things,” says Angela Mills, MD, chair of emergency medicine at VP&S since 2018. “When Lorna was working on a project she put in 110 percent. She would make sure to research everything, talk to everyone, really look into it deeply to uncover any potential issue or challenge,” says Dr. Mills, who is the J.E. Beaumont Professor of Emergency Medicine. “She was very thorough and brought this zeal, this energy. You knew it was going to be done well.”

Dr. Breen brought equal zeal to her personal life. She ran marathons, joined Toastmasters, took turns hosting a book club, and participated in a close-knit Bible study group whose running email thread of prayer requests sustained their connection even when they couldn’t meet in person. When she finally bought her dream car in her 40s, her choice—a black Porsche 911 convertible—earned her some good-natured ribbing about a midlife crisis. Dr. Breen took salsa classes, dragged friends out to dinner, took cello lessons, and joined the beginners’ chamber group for the New York Late Starters String Orchestra; over time she advanced to play in the orchestra itself. And once a year, Dr. Breen hosted a party on the rooftop of her West Village apartment building in Manhattan, assembling loved ones from every facet of her life. 

In early March 2020, Dr. Breen joined her younger sister, Jennifer Feist, for a family snowboard trip in Montana. She zipped down the slopes—clad in a bright orange puffy jacket—with her niece and nephew, then lounged in the hot tub with her sister, brainstorming party plans for Dr. Breen’s upcoming 50th birthday. As the world news focused on COVID-19, Dr. Breen monitored work emails about NewYork-Presbyterian’s preparations for the expected cases. By March 14, when she returned to work, the case count at NewYork-Presbyterian had exploded. Personal protective equipment, oxygen tanks, even health care workers themselves were in short supply as illness and quarantine thinned their ranks. Within four days, Dr. Breen herself was infected. 

A Return to Work but not the Same 

When Dr. Breen returned to work in April, she was changed. Once unflappable, she had trouble keeping up with the flood of patients and changing protocols. Once adamant about getting a full eight hours of sleep every night—she had penned a literature review early in her career about the physical and mental hazards of exhaustion among emergency doctors—she finished 12-hour shifts then kept working. No one was going home, she told Ms. Feist; the need was just too great. “She said it was like Armageddon,” Ms. Feist recalls.

Perhaps no one grasped the toll of those days more clearly than Ms. Feist. Born just 22 months apart, the sisters grew up sharing a bedroom and wearing coordinated outfits; they had their own secret language. In adulthood they texted constantly, spoke daily on the phone, and traveled together domestically and internationally. The two were “attached at the hip,” says Ms. Feist’s husband, Corey.

On April 9, Dr. Breen called Ms. Feist from her West Village apartment. She hadn’t slept in a week; she’d given up, she said, and needed her sister to take over. Ms. Feist, living in Virginia, offered to buy Dr. Breen a plane ticket. She couldn’t get to the airport, Dr. Breen replied; she couldn’t even get out of her chair. While Mr. Feist contacted Dr. Mills to stay with Dr. Breen, Ms. Feist contacted friends to drive Dr. Breen south. Ms. Feist met her sister in Baltimore and the two drove directly to the University of Virginia Medical Center, where Dr. Breen spent the next 11 days in the psychiatric inpatient unit. Five days later, Dr. Breen was dead.

After her release from the inpatient unit, Dr. Breen had anguished over her professional fate. “This is a career ender,” she told her sister on multiple occasions. “I’m going to lose my license and I’m going to lose my job.” When Dr. Mills sent an email to emergency department staff a few hours after Dr. Breen’s death, she honored the family’s request for privacy concerning the cause of death. 

The next day, however, a New York Times headline read “Top E.R. Doctor Who Treated Virus Patients Dies by Suicide.” On Twitter the news spread like wildfire.

The Feists knew that shame, stigma, and a culture of stoicism compel many doctors to power through exhaustion and psychic pain. And they had every reason to suspect that many more doctors on the front lines were suffering as Dr. Breen had. 

Out of Pain, a Promise 

And so the Feists determined to seize the opportunity they had been given to shine a spotlight on the need for mental health support for health care workers and spare others the agony Dr. Breen had endured. “It’s much bigger than Lorna, than one person,” says Mr. Feist, who now speaks regularly on behalf of the Dr. Lorna Breen Heroes’ Foundation, the nonprofit he and Ms. Feist founded. “The story has evolved from that of a tragic suicide to an issue that affects health care workers in this country and all around the world.”

The rate of deaths in the United States attributed to suicide has increased every year from 2000 to 2018, and health care workers are at particularly high risk. Among medical students, trainees, and early-career physicians, suicide is the leading cause of death. Among doctors over age 34, suicide is the second most common cause of death. Health care workers, broadly, are twice as likely to die by suicide as the general population, in part because they have the expertise to make their attempts more devastating. And while many suicide deaths go unreported, current data suggest that physicians die of suicide at a rate of one every day. Women and those practicing emergency medicine are at highest risk. 

In recognition of the extreme mental health risk her staff faced as the pandemic surged in late March, Dr. Mills partnered with the Department of Psychiatry to institute virtual peer debriefing sessions for staff throughout the emergency department. “There was a sizable group who were attending,” says Dr. Mills. Facilitated by psychiatrists and psychologists, the groups provided a structured environment for staff to discuss their experiences and express their concerns among people who understood what they were going through. “A lot of what we see and do is hard to talk about with people who aren’t in the medical field,” says Dr. Mills. “With COVID, that’s been much more significant and challenging.”

In early April, the VP&S Department of Psychiatry launched Cope­Columbia in partnership with ColumbiaDoctors and NewYork-Presbyterian to offer free, confidential access across the medical center to counseling sessions, peer support groups, guided meditation, suggested reading, and other resources for managing stress, fear, and anxiety. 

After Dr. Breen’s death, Dr. Mills scheduled one-on-one sessions for everyone to see a therapist. “People could opt out,” she explains, “but I felt it was really important to make it as easy as possible for people to get support.” Among the 70% of the staff who participated in those initial sessions, more than 20% continued with further sessions. “There was a need,” says Dr. Mills, who recognizes the pervasive stigma among health care workers of seeking help. “We need to do a better job normalizing mental health care among providers. If someone had surgery on their knee, we would ask ‘How are you doing?’ As leaders, the best thing we can do is talk about mental health, remove the stigma.”

The Science of Suicide

J. John Mann, MD, the Paul Janssen Professor of Translational Neuroscience in Psychiatry and Radiology, echoes that sentiment: “Doctors are designed to give help. They’re less good at getting help.” Compared with members of the general public, physicians are less likely to have a personal physician or get regular physicals. “They ignore their own health or wing it, ask a colleague down the hall about a symptom they may have noticed.” That’s why efforts like Dr. Mills’ opt-out counseling sessions can be lifesaving, Dr. Mann says; doctors are no less likely than the general population to have depression, but they are less likely to be screened or treated.

In October 2020, the American Journal of Psychiatry published Dr. Mann’s model of suicidal behavior, a framework he began developing in the late ’90s to identify opportunities for intervention among people at greatest risk of suicide. “Suicide is not just a simple result of extreme stress,” he notes. Nor is it an inevitable outcome of major depression or post-traumatic stress disorder, whose symptoms can ebb and flow over the course of a lifetime. Rather, he explains, death by suicide represents a synergy of nature, nurture, and opportunity. Stressors like job loss, divorce, or trauma can trigger suicide in those already weighed down by depression and having a predisposition—diathesis, in the model’s parlance—to respond to despair and hopelessness by suicide. That predisposition is itself an outcome of an individual’s unique genetic and epigenetic characteristics. “Once you understand the propensity and the role of the stress, it becomes clearer why people die by suicide and opens up opportunities to intervene.

“For front-line workers, COVID-19 is a constant and ongoing stress,” says Dr. Mann. In the wake of the 9/11 terrorist attacks, multiple studies documented spikes in depression and PTSD among people who had been most closely affected. That event, however, was comparatively brief. “COVID has placed health care workers under chronic, relentless, unpredictable, severe stress. They have worked until they dropped. A number of them became exhausted physically and mentally and some of those doctors had a predisposition to depression and suicide that they knew nothing about.”

Furthermore, says Dr. Mann, viral infection itself can wreak havoc on mental health. “Viral illnesses like influenza are known to trigger depression in certain individuals and increase the suicide rate,” he says. Autopsies have shown that among people who die by suicide, heightened inflammation in the brain is more common. “The inflammatory response directed at a virus can spill over into the brain and affect brain function,” says Dr. Mann, who points to evidence that COVID-19 triggers severe inflammation throughout the body, and infection can affect neurological symptoms even if viral particles never cross the blood-brain barrier. “COVID-19 is notorious for provoking an extreme immune response and has the potential to trigger suicidal behavior.”

Destigmatizing Physician Suicide

On Physician Suicide Awareness Day on Sept. 17, 2020, Dr. Mann joined the Feists, other health care professionals, and national leaders for an online discussion about evidence-based tactics to reduce suicide risk at Columbia and throughout the health care industry. Dr. Mann champions ongoing outreach and education both about mental health risk factors, as well as support services, such as 24-hour text and phone counseling and access to free, same-day appointments. “For physicians, that is probably one of the most important things,” he says. “Lower the barriers to attaining quality help.” And given the stigma, confidential and even anonymous support services can be vital. 

Devjani Das, MD, VP&S associate professor of emergency medicine, organized the Physician Suicide Awareness Day discussion. If the pandemic has a silver lining, Dr. Das says, it’s the spotlight that has been shone on the hazards health care workers endure and ways to mitigate those risks. “It’s no longer a conversation behind closed doors. People recognize it can happen to themselves, to people they love.”

Bernard Chang, MD, PhD, associate professor of emergency medicine at VP&S, met Dr. Breen in 2012 on his first shift as an attending at the Allen Hospital. “She could tell I was super anxious for my first shift as a grown-up doctor,” says Dr. Chang, now vice chair of research for the department. “She actually stayed while I saw my first patient, to make sure I was doing OK.” Over time, the two became friends and in 2019 co-authored an analysis of burnout prevention in the American Journal of Emergency Medicine. “Lorna was a true intellectual, always asking the why questions. And she would always bring it back to something translatable and meaningful in the short term that could have an immediate impact for patients and providers.”

To extend Dr. Breen’s legacy of practical, evidence-based interventions to promote physician well-being, the Feists have championed the Dr. Lorna Breen Health Care Provider Protection Act, bipartisan federal legislation introduced in both the U.S. Senate and House of Representatives. The legislation would create behavioral health and well-being training programs as part of a national campaign to encourage health care workers to seek support. Through the Dr. Lorna Breen Heroes’ Foundation, the Feists also have become proponents of changes to the questionnaires used by some state licensing boards and health systems that require physicians to disclose mental health diagnoses and treatments, in violation of the Americans with Disabilities Act. 

“What we learned after my sister’s death is that her fears for her job, for her license, and frankly even her concern for the respect of her colleagues were not off base,” said Ms. Feist during the Physician Suicide Awareness Day event. “Our expectation that our health care providers be superhuman with no needs, no fears, and no need for rest has to change. The burnout rate, the anxiety, the depression, the increased rate of suicide, why does this have to be part of the job? My sister needs to be the last one who dies like this.”

The VP&S Department of Emergency Medicine created an annual lecture series to honor the memory of Dr. Breen. It will host leaders who will promote her passions of professional development, love of learning, and the importance of continued growth. The inaugural Dr. Lorna Breen Annual Lecture was held April 21, 2021. See more.

Dr. Lorna Breen Heroes’ Foundation: http://drlornabreen.org.