A Doctor's Emergency
The suicide of New York emergency doctor Lorna Breen at the height of the city's COVID pandemic was front-page news—and opened up a painful conversation about what we ask of our overworked first responders. Her still-grieving family hopes it can lead to widespread change in a professional culture often disinclined to take its own mental health seriously.
By Maureen O'Connor
Dr. Lorna Breen during the NYC Marathon in November, 2008.Courtesy of Corey Feist.
Each year in March, Dr. Lorna Breen would join her sister Jennifer Feist's family for a spring break ski trip. This year's destination was Big Sky, Montana. The medical director of the emergency department at upper Manhattan's NewYork-Presbyterian Allen Hospital, and an assistant professor at Columbia University Vagelos College of Physicians and Surgeons, Breen had a reputation for tireless work and adventurous pursuits. (She once traveled to Croatia to study for medical board exams, to make a working vacation of it.) Tall and athletic with a bright grin, Breen arrived in Big Sky on March 8, when New York City had 13 confirmed cases of COVID-19. For five days she snowboarded—and her family skied—while keeping an eye on the news and excusing herself for phone calls with colleagues.
Breen took her 12-year-old niece on a black-diamond ski run that week. She discussed her upcoming 50th birthday over wine in the hot tub with her sister. Breen also talked about the pandemic with Feist. Infectious disease was not an uncommon topic for them. Feist's 16-year-old son had been hospitalized, at age six, when he contracted swine flu during the H1N1 epidemic in 2009. During the 2014 Ebola outbreak—in which a NewYork-Presbyterian/Columbia physician had been infected—the sisters discussed the risks that first responders face when asked to contain an unfamiliar illness.
"She started saying things like, 'This is really bad,' 'This country isn't ready,' 'We don't have the supplies,' 'We don't have the protocols,'" Feist said of conversing about COVID-19 with Breen. The doctor left Big Sky on March 13. She loaded her things into a rental car and hugged her family goodbye. "We basically just said, 'Good luck. Keep us posted,'" Feist said when we first spoke in May. "In retrospect, I wish I had said, 'Here's an idea. Quit your job right now.'"
Breen returned to work on March 14, the day New York officials confirmed the city's first COVID-19 death. Over the next six weeks, the city's death rate would spike to six times its normal level. Some days, New Yorkers would call 911 at rates surpassing those of the September 11 attacks, pushing emergency systems and personnel past their limits. Breen, who had a reputation for calm under pressure and no known history of mental illness, would suffer a mental health crisis. She died by suicide on April 26. She was 49 years old.
The day after Breen's death, the New York Times published an article in which Breen's father, a retired trauma surgeon, confirmed the cause of death and described Breen as a casualty of the pandemic. For a general public struggling to grasp the breadth and depth of the novel coronavirus's tolls, the tragedy struck a chord. Breen's life had been full: She had her dream job, a loving family, and the energy to pursue and conquer seemingly anything. She played cello in an orchestra, belonged to a Bible study group, enjoyed salsa dancing, and was working on an executive MBA/MS degree in health care leadership. She made friends everywhere, and threw a party for them on the roof of her West Village co-op every summer. A life of perpetual motion had ended unexpectedly. New York City was in lockdown, and in the next six months, most Americans would experience partial and temporary halts. Nearly 200,000 Americans have died of COVID-19. Breen's death came amid all of this loss—her degree unfinished, her orchestra's next score unlearned—for reasons difficult, if not impossible, to comprehend.
"This is not how the story is supposed to go," said Dr. Barbara Lock, a NewYork-Presbyterian emergency physician who first worked with Breen around 20 years ago, during their residencies. "It still barely makes sense to me. It makes a little bit of sense because I was there, and I know how awful it was in the emergency department, and how much suffering there was all around us, and how many people were dying in front of our eyes," Lock said. "I can imagine her despair because I felt a pretty significant despair, myself." But Breen's suicide shocked her: "That is not the story that I expected. That is not the end."
Nearly five months have passed since Breen's death. The sound of sirens has receded in New York City. The curve has flattened. Schools are reopening. But the stresses of the surge seem, to me, not diminished but dispersed. COVID-19 remains in the population, as does the struggle to compensate for it. Some elements of life have accelerated. (A young family moves to the suburbs ahead of schedule; a struggling business takes down the shingle.) Other trajectories have slowed. (A wedding postponed; a college semester deferred.) Others have redirected.
The first time I spoke to Jennifer Feist, in May, she had not yet brought herself to scan into a computer her sister's death certificate, which she needed to do to get Breen's affairs in order. But she had already met virtually with representatives from the American Medical Association, the American Psychiatric Association, National Academy of Medicine, the American College of Emergency Physicians, the Physicians Foundation, the Surgeon General of the U.S. Air Force, the office of the governor of Virginia, and Senator Tim Kaine. In the days following her sister's death, with husband Corey Feist, Jennifer launched the Dr. Lorna Breen Heroes' Fund to support the mental health of health care professionals. (Like her sister the ER doctor, Jennifer seems to have a knack for fast, practical action amid crisis.) In subsequent months a Dr. Lorna Breen Health Care Provider Protection Act was introduced to the U.S. Senate and the House of Representatives, both times with bipartisan support. Six months ago, physician suicide was barely on Feist's radar: "This is the worst nightmare I never knew I had," she said in August. Now her late sister is the face of the issue, and she and her husband are high-profile advocates.
Over the course of the summer, I spoke with the couple a number of times. Their pain was enormous. Their frustration, as they watched Americans struggle with COVID-19, was deep. ("Who's going to help them?" Jennifer asked of those who seemed, to her, cavalier about public health. "Somebody like my sister, who maybe has been doing this since March.") But their motivation, even as they grieved, was astonishing. They were back at their full-time jobs even as they worked overtime to change the conditions they believe contributed to Breen's death. "We just need to keep moving," Corey said in July, after explaining how the demands of electronic medical records affect physicians' stress levels. Securing Breen's legacy has, he said, become part of their grieving process. When a story ends unexpectedly, there will inevitably be another story, with another ending, about those who survived. This one includes a bereaved family questioning whether the unexpected could have been prevented.
Lorna and Jennifer at Barboursville Vineyard in the summer of 2018.Courtesy of Corey Feist.
In her 49 years, Dr. Lorna Breen did everything that could have been expected of her. She was the kind of person you'd invent if you were trying to describe a platonically good person: a literally lifesaving, straight-A student who loved her family, ran marathons, and went to church. She played by the rules. She used education as a ladder. She knew that doing everything means risking burnout, and took action to avoid that too—in the final years of her life, Breen studied burnout. And she still burned out. When COVID-19 arrived in New York City, Breen continued to play by the rules. She followed the CDC's guidelines for handling the illness, including rapidly changing advice about personal protective equipment—even when PPE was in short supply. And she still got sick. She was surrounded by people who understood mental health. Her colleagues at NewYork-Presbyterian and Columbia worked proactively to support pandemic-stressed workers. Her colleagues nationwide have been calling attention to physicians' mental health for years. And they still lost Breen.
"She got thrown in the fire, which she signed up to do," Feist said of her sister. "But I don't think people realize or understand what that actually means." Breen died at a time when saving lives required confronting an unknown disease with untested treatments. But the cause of her death, suicide, is a well-known phenomenon. Mental illness can be treated. If Breen was thrown into a fire, then it was one that sparked other emergencies and accelerated other problems—the kind that a distressed person could internalize and turn into a crisis within.
If you need emotional support or are in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255.
Lorna Margaret Breen was born in Charlottesville, Virginia, on October 9, 1970. Her father, Dr. Philip Breen, the son of a stonemason, was a medical resident at the University of Virginia at the time. Her mother, Rosemary Breen, the daughter of Armenian refugees, was a nurse. She had a brother nine years her elder, Michael, who is now a radiologist. Her sister Karen, six years older, is now an artist and works in the public school system. The family's youngest, Jennifer, was born 22 months after Lorna. They grew up sharing a bedroom. Rosemary sometimes dressed them in matching outfits, with each girl's dress coordinated with the other's hairbow. The pair remained confidantes in adulthood, said Feist, and talked on a daily basis.
"My earliest memories involve my sister. She's just always been there," said Feist. "When did you notice you had a hand? I don't know, it's just always been there. That's the way it was with my sister. We were just always together." Before the younger sisters entered grade school, their family moved to Danville, Pennsylvania. Feist described the household as religious, and their parents strict. Breen got her first job when she was 14, picking strawberries at a local farm.
"She was always the smartest one in the family," Feist said of her sister. "She definitely had an idea of what she thought a cool life would be. And it was being a doctor in Manhattan, and traveling the world." When Breen was a teenager, her parents divorced. She set her ambition on boarding school, and won a scholarship to attend the Wyoming Seminary. She graduated from Cornell University in 1992, and the Medical College of Virginia in 1999. Her residency, at the Long Island Jewish Medical Center, was a dual program that yielded certifications in both emergency medicine and internal medicine. She selected the program because she knew her dream job, practicing emergency medicine, would be high stress. She wanted a contingency plan.
"She was tough," Dr. Barbara Lock said of working with Breen early in their careers. "And she always looked absolutely stunning," Lock laughed. "Everyone knew that Lorna put her whole heart into the Allen emergency room," said Dr. Angela Mills, chair of the department of emergency medicine at Columbia University Vagelos College of Physicians and Surgeons and chief of emergency medicine services, NewYork-Presbyterian/Columbia. Both women emphasized the depth of Breen's care, particularly for her colleagues. Lock grew emotional as she recalled a day, several years ago, when a young patient's struggle hit her hard. "Lorna came in and said, 'Don't worry, I'll take care of it,'" Lock remembered. "And she stayed at the bedside for an hour."
Breen was a planner. She would email her schedule, sometimes months in advance, to friends whom she would invite to join her travels. "She was very methodical, both in medicine and outside," said longtime friend Dr. Eugenia Gianos. Lisa Flom, who traveled with Breen to Paris and New Orleans, described the doctor as fun-loving but conscientious, always insisting on eight hours of sleep. She had a dry sense of humor and a taste for oaky Chardonnay: "She had the worst taste in wine," Flom laughed. "She would actually agree to that."
Breen tested positive for COVID-19 in late March. She spent the week of March 22 alone in her apartment, exhausted and sleeping up to 16 hours a day, according to Feist. She was in touch with family, friends, and some coworkers who were also home sick with COVID-19. "At one point approximately 20% of our physicians were out on quarantine," Mills said of Columbia University's emergency medicine department, which staffs four of NewYork-Presbyterian's nine emergency departments.
When Breen's fever subsided she waited three days, then returned to work on April 1, when local infections—and deaths—were surging. That day, Breen called her sister. "She was saying, 'It's like Armageddon,'" recalled Feist. The city's hospitals were overflowing. The emergency department at the Allen, which served hard-hit communities in upper Manhattan and the Bronx, was treating about three times as many patients as its usual capacity. Breen described supply shortages and staggering deaths.
One of Breen's colleagues described the stresses of late March and early April as the layers of an onion. Staffing was short and constantly changing. Beds were in short supply. At times, there were lines of ambulances waiting to admit patients. Portable oxygen tanks were frequently deployed. To reduce the risk of accidental exposure, some workers avoided or lived separately from their families. Each stressor layered over the next. At the core was the disease itself, and the inescapable difficulty of treating an illness while experiencing and learning about it for the first time.
On April 4, Gianos texted Breen to ask how she was doing. "I'm doing better, but dealing with the devastation in the ER, struggling a bit," Breen replied. She had insomnia, which was unusual for her. On April 9, Breen called Feist in despair. "She was saying things to me like, 'This is the end of my career. I can't keep up,'" said Feist. She said she wanted to die, a remark so out of character that Feist compared it to hearing someone speak in tongues.
"I hear these stories about pilots," Feist told me in June. "When they're in distress, they say, 'My plane,' and then they're in charge. And the cocaptain says, 'Your plane,' to acknowledge who's in charge."
Feist took control. She arranged for two friends to drive Breen, in a relay, out of the city and to Maryland. Feist drove up from Virginia to meet them. Jennifer's husband, Corey, called Mills, who offered to check on Breen in person. "It was clear to me that she needed help," said Mills. "She was not the same Lorna." That evening, Jennifer Feist brought her sister to the ER at the University of Virginia Medical Center. Breen spent 11 days in the hospital's in-patient psychiatric unit. Breen's mother worked in that unit as a psychiatric nurse for two decades until her retirement in 2006.
While she was in the hospital, Breen worried about her career. She texted Flom, who works in human resources, for advice about taking a leave of absence. Jennifer Feist called NewYork-Presbyterian/Columbia University to arrange for one on Breen's behalf. The process went smoothly, Feist said, but Breen continued to worry.
"When she got out of the hospital, she kept saying, 'This is a career ender,'" said Feist. Her sister was catastrophizing, which can be a feature of mental illness. But even among doctors, seeking psychiatric care can carry stigma: A number of state medical licensing boards require doctors to disclose their personal psychiatric histories in ways that may not comply with the Americans With Disabilities Act—and which, Feist argues, contributes to a culture that associates seeking help with weakness. "She didn't want anybody to know what happened," Feist said of Breen's mental health crisis. She contrasted that with Breen's experience, around five years prior, with suffering and treating a pulmonary embolism: "She didn't hesitate to tell anybody."
After leaving the hospital, Breen stayed first with her mother, then with Feist. Breen seemed, to her sister, to be in recovery: She was planning for the future and going on runs to Target for workout clothes and face masks. Five days after leaving the hospital, Breen died.
In the hours after Breen's death, on the last Sunday in April, shocked members of her family gathered in Jennifer Feist's backyard in Charlottesville. "We obviously had no plan to tell anybody," Feist said of her initial approach to her sister's suicide. "I might have just said, 'She died,' and left it at that." But in the next two days, Breen's suicide would become international news. Grief always changes the lives of those who survive, but for Feist the change has included a move into public life—unwittingly, at first, and then purposefully. "I have wondered if this is Lorna's gift to us, because everybody knows and there is no hiding it," Feist told me in August. "And so our feeling was, if everybody knows, then, fine. Let's talk about it."
"What I want people in the health care industry to know is that this happened so quickly," Feist said. "It wasn't the kind of thing where we had been struggling for years, or even a year, or even a month," she continued. "I didn't realize this was a possibility."
Corey, Charlotte, and Lorna in Big Sky, Montana in March, 2020.Courtesy of Corey Feist.
Due to restrictions on social gatherings, mourning Breen required modification. There were Zoom memorials for family and for colleagues. Breen's mother wrote a eulogy, but at one memorial, was too distraught to deliver it; Feist read it aloud on her behalf. Flom and Gianos wore masks, and sat six feet apart, to grieve with another friend in Central Park. Every day at 7 p.m., when New Yorkers leaned out their windows to clap in thanks for first responders, a group of Breen's colleagues from Columbia and the Allen Hospital emergency department would meet on the corner of 72nd Street and Central Park West, by the Strawberry Fields. "We would just stand there, and we would clap," said physician Dr. Bernard Chang. "It was just a time for us to look at each other and say, 'Oh, my God, she's gone.'"
Physicians are believed to die by suicide more than the general population. Precise numbers are difficult to ascertain, but estimates range as high as double the rate of the general population, according to a study presented at the American Psychiatric Association's annual meeting in 2018. (Limited data and underreporting constrain understanding of the issue.) Some research suggests that female physicians die by suicide at higher rates than their male peers.
Why might physicians be at risk? Theories on the subject are numerous, as are the factors that contribute to any one suicide: depression, genetics, stress, neurobiology, personal histories, social environments, and more. When I asked Dr. Thomas Joiner, a professor of psychology at Florida State University and author of Why People Die by Suicide, he pointed out that any of those factors, combined with a professional familiarity with death, could be at play. "There are other occupations like that: law enforcement, military, firefighters," Joiner said of those accustomed to life-threatening situations, injury, and pain. "Often it's an admirable quality. It's useful and helpful. The trouble is that when it gets combined with misery and desperation, it can turn from something that's admirable and useful to something that's dangerous and self-destructive." Two days before Breen's death, a 23-year-old New York City EMT died by suicide. According to the New York Post, he had also confided about job-related stresses prior to his death.
Jennifer Feist believes that Breen's COVID-19 infection could have made her brain more, or newly, vulnerable. Scientists are still learning about the virus's neuropsychological effects; some associated conditions, such as low oxygen levels and encephalitis, can affect mood, behavior, and cognition. Researchers are also studying how the virus may infect the brain itself. "Her brain wasn't working and she couldn't keep up," Feist theorized. Some time after Breen's death, Feist Googled her sister's name and discovered that, in recent years, Breen had studied burnout in her workplace. In June 2019, the American Journal of Emergency Medicine published a letter in which Breen and three colleagues considered how changes within the workflow in the Allen Hospital's emergency department might combat "the alarming prevalence of clinician burnout." Breen's work joined a growing body of literature on the subject, including a call to action from officials at Harvard Global Health Institute, the Massachusetts Medical Society, and other institutions, that characterized physician burnout as a public health crisis in January 2019. Dr. Christine Sinsky, the American Medical Association's vice president of professional satisfaction, explained by phone: "We know that going into medical school, medical students start with a stronger mental health profile than their age-matched peers. And yet within a couple of years, they have rates of burnout that are significantly higher."
Chang, one of Breen's Central Park West mourners, had been working with her for several years when she brought up clinician burnout. An emergency physician with a doctorate in psychology, Chang regularly worked under Breen's direction at the Allen Hospital. He also studies how stress plays out in hospital environments. Breen theorized that if groups of doctors, nurses, and technicians at the Allen worked together in consistent teams—instead of different permutations of coworkers for different cases—their well-being would improve. "Her personal belief was that we're stronger together," said Chang. When Breen implemented the team-based care plan in the ER, she worked with Chang and two other colleagues to study the outcome. Breen's intuition was correct: Working together reduced burnout.
Chang said Breen never discussed any personal feelings of burnout: "I still beat myself up thinking: I'm a psychologist and I study burnout. Why the hell couldn't I have helped Lorna more?" He paused. "I didn't pry too much. She always exuded such competence and confidence. She was the quintessential provider. I wasn't able to get any inkling that she was experiencing anything herself."
Many people I spoke to expressed agonies similar to Chang's. Their regrets were painful to hear. "When you look back, you're like, Did I miss something?" said Flom, who replied by text message to Breen's inquiry about taking a leave of absence, but now feels badly that she didn't call. Gianos said she's learned to view Breen's text message about struggling as a cry for help. Over the years, Jennifer Feist had occasion to discuss suicide with her sister, including after the deaths of fashion designer Kate Spade and celebrity chef Anthony Bourdain: "She thought it left a really difficult legacy of pain for the family who remained," said Feist. "She didn't believe in it."
The second week of March, while Breen was still in Montana, Columbia University's clinical vice chair of psychiatry, Dr. Lourival Baptista Neto, started work on CopeColumbia, a mental health care program for employees of Columbia University Irving Medical Center, including physicians who work at NewYork-Presbyterian. The program organizes psychiatrist- and psychologist-led peer support groups, one-on-one therapy, and virtual town halls. In the months after CopeColumbia's launch on March 23 (when Breen was out sick) peer support sessions for workplace teams—starting with patient-care providers in NewYork-Presbyterian/Columbia's ERs and ICUs—were particularly popular. The program has been running ever since. Baptista Neto knew Breen, but did not work closely with her. After Breen's death, Columbia's emergency medicine department scheduled one-on-one CopeColumbia sessions for emergency physicians, who could opt out if they chose. In the the first week, more than 70% attended.
Baptista Neto said that, across CopeColumbia, nearly one third of the people who requested one-on-one support "required further intervention," meaning a clinical appointment. "The reasons varied from severe sleep disturbances, going on several days and sometimes weeks, to panic attacks, to ongoing depression," he explained. But Baptista Neto was also quick to note that, even among those who experienced mental distress, most did not develop diagnosable psychiatric conditions. Nor did most experience drastically negative outcomes. Burnout alone, he said, does not cause suicide. But when combined with other risk factors—such as preexisting mental health problems—acute stress can be a catalyst for crisis.
"I think the stigma is such a big problem for physicians," said Baptista Neto, describing a culture that associates seeking help with weakness. "Very often that prevents people who have predispositions and vulnerabilities from getting the help that they need."
Flooded with press requests in the wake of Breen's death, Jennifer and Corey Feist granted an interview to the Today show. Both Feists are lawyers. Jennifer has experience with nonprofits, and Corey is the CEO of the University of Virginia Physicians Group. (He's an executive in the health system that treated his sister-in-law and employed his mother-in-law.) When the Feists appeared on television, days after Breen's death, they told viewers about the fund they had already launched in her name.
"We want to have a culture where it's easy to ask for help," Senator Tim Kaine said in a virtual press conference about the Dr. Lorna Breen Health Care Provider Protection Act. In a contemplative moment he asked, "Do we even make it harder for people to seek help if we put them on a pedestal?"
"There is this culture of being a badass, especially in that profession," said Jennifer Feist. Since Breen's death, she has heard from people who recount how, starting in medical school, they were encouraged to push past their limits. She has heard from people who lost loved ones, both within the medical profession and without. "I'm not exactly sure why my sister's story is the one that everybody heard about," said Jennifer. "But I think the more we shine a light on this, the more it goes away."
This fall, the Association of American Medical Colleges will feature the Dr. Lorna Breen Heroes' Foundation at its annual national meeting, which will be held online. (The speakers include Dr. Anthony Fauci.) When U.S. News & World Report released its annual Best Hospitals ranking in July, Jennifer and Corey Feist wrote a corresponding guest post. In it, they argued that the rankings ought to include information about the well-being of each hospital's staff. Corey has since expanded the effort to other third-party hospital observers. "Lorna is the canary in the coal mine," he said in September. "We don't necessarily need a stronger canary. We need a new coal mine."
Dr. Christine Sinsky was listening to a conference call while driving her car in Madison, Wisconsin, in May when she first heard Jennifer Feist tell her sister's story. She pulled over and stopped the car, then sat listening. "We were already working on these issues, but it just put it into context so clearly," said Sinsky, who practiced medicine for 31 years and began working at the AMA in 2013. "We're humans. We respond to stories," Sinsky said in an interview in July. "I was impressed with their decision, within 24 hours of Dr. Breen's death, to lean into the issue rather than what would be, I think, human nature, to pull back." Sinsky contacted the Feists and put them in touch with the AMA's Advocacy Resource Center, which arranged for them to tell their story again, this time on a Zoom call with over 100 leaders from state medical societies—people who can influence the state-level licensing issues that the Feists believe deter doctors from seeking mental health care.
Americans are somewhat accustomed—perhaps disturbingly accustomed—to watching grief-stricken families mourn and advocate simultaneously. Pulled into the public sphere for something they wish that did not happen, their power comes, in part, from their willingness to retell that story. When I spoke to Corey Feist about the Dr. Lorna Breen Heroes' Foundation, he invoked Mothers Against Drunk Driving, an organization founded on one mother's tragic story. Her account was specific enough to be memorable but universal enough to be embraced so widely that public sentiment about drunk driving and numerous laws changed.
The goal, for this foundation, is to change the norms and laws around medicine. "We were in a position to take that burden and to share that," said Corey. But I was surprised, while working on this story, how many people with no ties to medicine said Breen's death had prompted them to check in with a loved one, or ask for help, or speak openly about a family secret. The power was not just the story—it was the fact of the story, and who was telling it, and how. Contextualizing Breen's death as part of the COVID-19 pandemic meant thinking about mental health in the context of public health, and death caused by mental illness as, plainly, death caused by an illness.
"When the unspeakable happens to you, and you speak of it, it gives others permission to come forward," Corey Feist said in August. He was quoting a member of the American Group Psychotherapy Association who had reached out to his family after reading about Breen in the news. Since his sister-in-law's death, like-minded people have been reaching out. There is a consensus. Working with the Physicians Foundation, Jennifer and Corey Feist will make several virtual media appearances this week for National Physician Suicide Awareness Day on September 17. The couple prefers to be interviewed in tandem. They're stronger together.
"People need to be human," said Jennifer. "Doctors need to be able to be human."
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