It was March 2020, deep in the pandemic. In the general internal medicine unit of a downtown hospital, resident Neha Puri (MD ’19) plunged into providing care to patients with severe COVID-19 symptoms. One patient — a man in his 80s with a lung injury — had just died. Puri had to FaceTime his family members across the continent to let them know about his death.
By Hilary Caton
Once finished, she rushed through the hallway to make it to the call room before her tears started. Even today, more than three years later, the man’s death is one of the enduring memories of Puri’s pandemic experience.
“I don’t think we — heath care providers — have had time to process what happened. I think we’ve just moved on. You have to do that in the line of work that we do,” says Puri, who is now a general internal medicine fellow at the Temerty Faculty of Medicine’s Department of Medicine.
Her words echo those of many front-line clinicians whose stream of patient consults and daily rounds haven’t stopped or stemmed. Meanwhile, the effects of the COVID-19 pandemic are still being uncovered. And, what isn’t known yet is how these memories will affect us.
There’s also the complicating factor that recollections of life during COVID-19 — and the lockdowns — have taken on an elusive shape for many, even though the ramifications persist. Some say the memories of washing their groceries and queueing for toilet paper feel like they transpired far longer ago than the three calendar years that have elapsed since WHO declared COVID-19 a pandemic.
Why are some people forgetting what was such a profoundly traumatic time? Some of this forgetting might be the nature of memory itself.
FORGETTING AS A FORM OF LEARNING
Instead of seeing forgetting as bad, like misplacing or losing important information, it requires a shift of perspective. The act of forgetting could actually be good for our cognitive abilities, say researchers.
“Generally, we forget things because remembering absolutely everything could be a source of confusion and a waste of energy,” says Paul Frankland, a professor in Temerty Medicine’s Department of Physiology and Institute of Medical Science.
Forgetting is a necessary process for our brain to eliminate irrelevant information and learn new information, says Frankland. In fact, it has a name – neurogenesis. Frankland and Blake Richards made headlines around the world in 2017 when they published a study that says the process of forgetting is beneficial to overall decision-making. In the study, the researchers found that the interaction between remembering (known as persistence) and forgetting (known as transience) allows for smart decision-making in situations in rapidly changing circumstances. Their study argues that forgetting enhances a person’s flexibility by reducing the influence of potentially old (and possibly useless) information on decision-making.
“We encounter a lot of information in our lives, and the vast majority of it is irrelevant to our everyday decisions,” says Richards, an associate professor at McGill University’s School of Computer Science and the Montreal Neurological Institute.
When it comes to processing memories, Richards says our brains can forget pandemic-related details, if we (potentially wrongly) perceive that they no longer apply to our lives. The important takeaways are broad-stroke ideas such as the importance of listening to public health officials and taking our collective responsibility seriously, says Richards.
“There is a process when we have to recall information to make a decision. The more you remember everything, the harder that process is going to be of sorting through to the relevant information,” he says.
THE MECHANICS OF MEMORY
Sheena Josselyn, a professor in Temerty Medicine’s Department of Physiology, says the way our brains form memories can explain wildly different recollections of the pandemic. Some forgetfulness is natural, and depends on a person’s unique circumstances.
“We’ve now stopped defining things as pre-COVID and post-COVID, so that signals to me that we are losing this big collective memory of the pandemic,” says Josselyn, a senior scientist at The Hospital for Sick Children.
The reason why some people have started to forget what life was like during the pandemic has to do with how our brains process and store memories, she explains. The human brain has a three-step neurocognitive process for forming memories. That three-step process means that to recall an event, a person must encode the memory, consolidate it and then be able to retrieve it later.
Excitatory neurons are particularly active when something important happens to a person, says Josselyn. Memories with emotional resonance, like the one Puri recalls, would be stored in amygdala. This is why we often remember events that have significant feelings involved — milestone moments such as births, weddings and deaths. It also helps explain why health care workers who confronted life-altering situations during COVID have very vivid memories of the pandemic.
For others who were in lockdown at home and mired in a similar routine every day, their pandemic experience may have felt mundane, and their memories of it could be fleeting.
“With COVID, there was nothing to anchor even the most basic memories in a timeline. Every day seemed very similar. So, it was hard to sort out how much time had elapsed,” Josselyn says. “When we lose the time and place, memories tend to get jelly-like, and they become hard to tie down.”
These jelly-like memories can get harder and harder to recall as time goes on, she says. Meanwhile, a traumatic memory — such as those experienced by people with post-traumatic stress disorder (PTSD) — can become more intense over time if a person replays the traumatic memory in their mind, says Josselyn.
“I could imagine that for some people, memories related to the trauma of the pandemic, and whatever happened to them, could be very intrusive,” she says.
People, especially those from historically and currently oppressed groups, may come away from encounters in the health system feeling more harmed than helped
WHAT THIS MEANS FOR HEALTH CARE WORKERS
During the pandemic, the strong relationship between mental health, health care workers and caregiving cannot be overstated.
“What we saw was a lot of health care workers extremely afraid of bringing the virus home. That is still talked about. People were traumatized,” says Rima Styra, an associate professor in Temerty Medicine’s Department of Psychiatry. “Even now, we’ve found health care workers have highly prevalent post-traumatic stress symptoms, symptoms of anxiety and symptoms of depression.”
The figures are grim. In a recent JAMA study looking at approximately 34,000 Ontario physicians, the pandemic was associated with a substantial increase in outpatient care for mental health and substance use, in this group. Demands for care went up 13 per cent, on average, during the first 12 months of the pandemic, compared with the 12 months leading up to the pandemic.
Styra also published research in 2022 that explored the relationship between emotional support, perceived risk and mental health outcomes among health care workers. She found that health care workers who felt unsupported in their work had higher odds of experiencing moderate and severe symptoms of anxiety, PTSD and depression. Feeling unsupported led to burnout, staff shortages and workers leaving the health care sector altogether.
“You get to know your patients and their families, and you really become involved in their lives in a way. You try to help, and sometimes the outcomes aren’t all that great. That was tough on health care workers,” says Styra.
ACKNOWLEDGING PROBLEMS
COVID-19 also highlighted embedded social inequities.
“I think that we still have a lot of work to do,” says Chase McMurren (PGME ’13), an assistant professor in Temerty Medicine’s Department of Family and Community Medicine and the theme lead for Indigenous health in the MD program. “People, especially those from historically and currently oppressed groups, may come away from encounters in the health system feeling more harmed than helped.”
In a 2021 Public Health Agency of Canada report, some of the First Nations, Inuit and Métis participants said that because of past experiences of systemic racism in health care, they felt uncomfortable accessing testing or health care services, and even more so during the pandemic. The report also states that institutional and systemic racism in health care and the allied health professions continues to be one of the biggest issues that many Indigenous peoples face.
A 2023 study by researchers including Modupe Tunde-Byass (PGME ’04), an associate professor in Temerty Medicine’s Department of Obstetrics and Gynaecology, found that the pandemic resulted in disproportionate challenges among racialized communities in Canada. The study acknowledged the deeply rooted mistrust that Black communities have for the health care system, which stems from a historical fear of being experimented on or offered ineffective treatment by health care institutions.
Racialized communities suffer from a significant lack of access to medical and mental health services, and have precarious and high-risk employment. The report also said that racialized communities lacked access to information about the pandemic. Approaching patient care and training overall with a trauma-informed lens is beneficial to all patients, but especially to those who distrust the health care system based on historical colonial trauma, says McMurren.
RESPONDING BETTER TO TRAUMA
Addressing the COVID-19 pandemic effectively also means acknowledging the need for trauma-informed learning at Temerty Medicine, as well as the importance of providing trauma-informed care for patients in general.
Shari Thompson-Ricci, Temerty Medicine’s equity, diversity and inclusion program coordinator and educator, is helping create workshops on trauma-informed learning environments for Temerty Medicine faculty and leaders, with Reena Pattani (PGME ’13 & ’14) and Allison Crawford (PGME ’05).
Thompson-Ricci says trauma-informed medical education taps into the six principles of trauma-informed approaches — safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment and choice; and cultural, historical and gender issues. The hope is that health care providers embody trauma-informed care and incorporate it into their practice, thereby creating a safer space for patients, the patients’ family and the entire health care team.
“The approach is multifaceted because it’s not limited to the health care provider and the patient, but it is also important to focus on applying the approach to interprofessional team collaborations, which can enhance patient care and improve health outcomes within the hospital,” says Thompson-Ricci. Training current and future doctors to be more trauma-informed is “extremely helpful,” she says.
“If we are being more trauma-informed and intentional about how we are educating our learners who are future doctors, if we have leaders within the medical school modelling this type of practice, it is absolutely going to help us in the long run, not just when we’re facing a pandemic,” she says.
REFRAMING MEMORY
Styra believes that not all memories of the pandemic have to be negative. For one, the pandemic created an emphasis on the well-being of health care workers, she says.
“Every kind of support is out there now for health care workers — individual support, group support, peer support and virtual support. There’s a tremendous number of options available. That didn’t happen before the pandemic,” she says.
Of the more than 3,800 health care workers Styra surveyed in her study, 77 per cent received emotional support from family, 74 per cent from friends and 70 per cent from colleagues. Having all three avenues of support makes a difference, she says.
For Puri, surviving the relentless march of the pandemic meant relying on colleagues and decompressing with people outside of the profession. A happy memory for her was the day when the Moderna and Pfizer vaccines came out — a “turning point” she celebrated with joyful tears on the phone with her sister.
“It had felt like we were going to war together. We could finally see some light at the end of the tunnel,” she says. Puri is now at the Dalla Lana School of Public Health earning a master’s degree in health practitioner teacher education. The dark memories of the pandemic — and 26-hour calls — didn’t put a dint in her love of medicine. If anything, they reinforced it.
“They’ve taught me the importance of humility in medicine, and to embrace the attitude of lifelong learning,” she says. “The pandemic taught me to take it one day at a time, and to know that we’ll figure it out together. There’s so much to know. Lifelong learning is something every physician should embody.” •
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