Myriad variables impact how a couple or individual shows up in therapy. These include demographic pieces, such as age, race, religion, ethnicity, cultural background, immigration history, sexual orientation, socioeconomic status, or gender identification. Other variables have to do with personal and familial history, such as where a person grew up, how often they moved, their level of education and education level of other family members, the extent and quality of their interaction with their community and other institutions, or medical history.
With that in mind, I want to discuss a very particular population, which is distinguished neither by demographics nor personal/familial history, but by profession: medical doctors and surgeons. Specifically, how medical doctors and surgeons relate to others and how they relate to themselves—and how both types of relationships might benefit from therapeutic intervention.
My motivation is both very real and very urgent: doctors and surgeons have the highest rate of completed suicide of any profession—more than twice the rate of the general population (webMD.com, 2018). Part of this has to do with the comparatively high lethality of their suicide attempts: physicians’ access to medication and medical tools, together with their knowledge of human anatomy and physiology, considerably reduces their likelihood of surviving a suicide attempt (webMD.com, 2018).
But tools and knowledge are not only to blame: physicians often experience extreme stress at work, have little time or energy for adaptive self-care, and find that there is a professional stigma against seeking help in the form of therapy or other behavioral health treatment—allowing, in some cases, undiagnosed substance abuse and mood disorders to run amok (webMD.com, 2018). These circumstances do not always result in suicide. However, there are still consequences: professional stagnancy and burnout, relationship dissatisfaction, low self-esteem, etc. While not as visible or extreme as suicide, these can still be serious and painful—and therapy can help.
Listed below are some common problems I have encountered while working with physicians. But do not be fooled! None of these problems are just problems, or always problems: particularly when it comes to high-functioning and goal-oriented folks—who are overrepresented in the physician population, to say the least—”problems” are often just strengths that have amplified beyond what is useful. If you are noticing these in your life or in your relationships, I guarantee individual, couple or family therapy can help [and hey, if you are not a doctor and you notice these problems, therapy can help you, too!]:
The idea of “work/life balance” is largely nonexistent for doctors and surgeons: they carry their professional identities everywhere. The work is demanding, and the hours are long; however, even during days or hours when doctors do not need to be physically present to care for patients (or available by phone and pager to answer questions), their professional identities—and the accompanying skills and responsibilities—follow them.
Maintaining geographic and temporal boundaries between work and life is always difficult and sometimes it is impossible: if someone collapses in a restaurant, the doctor on a date at the next table is back on the clock.
The Deceptive Appeal of External Validation
The path to becoming a doctor or surgeon is highly structured and very demanding. The journey begins with the completion of undergraduate classes, but some candidates for the profession are imagining their future and working towards that goal long before even that point. Then there is taking the MCAT, applying for medical school, passing didactic classes, completing practicum rotations, board exams, applying for residencies—and that is just the process for applying to and completing medical school!
After graduation, intensive training continues for at least a few more years—and up to a decade for the most competitive specialties. Throughout their education and beyond, doctors confront extremely high expectations for their competence, leadership, and work ethic. Predictably, medicine tends to attract and retain individuals who thrive on high expectations—but there can be a catch: faced with such massive and pervasive external demands, physicians may fall prey to the illusion that external validation is a reliable source of emotional gratification and self-esteem. Alas, it is not—and many get stuck in a cycle of dissatisfaction by chasing external validation.
Hyper-accountability is a term I coined to refer to the tendency to assume total responsibility in situations where responsibility should be shared. Attending physicians must assume clinical and legal accountability for their patients, as well as the actions of the other professionals working under them: and it is not an easy habit to break.
Resultantly, physicians often exhibit over-functioning in their personal relationships—that is, they shoulder more emotional or practical responsibility than is fair or reasonable. This may mean managing more tasks or doing more chores, but it can also mean hiding negative emotions, or making plans and decisions unilaterally: both done with the intention of sparing others bother and concern, but with the long-term effect of denying themselves help and support—and denying their loved ones the opportunity to provide it.
Physicians’ partners or family members may choose to under-function to accommodate and reinforce the over-functioning. That arrangement can remain stable for a while, but eventually cracks form and dysfunction emerges. Under-functioning individuals feel undervalued or overlooked, and wish to reclaim some authority in the relationship; over-functioning individuals feel exhausted and resentful, and wish for the help and support they systematically denied themselves.
The Problem of Prestige
The problem of prestige refers to the recursive interaction between the collective admiration of and alienation from physicians: they seem superior, and therefore impervious to criticism or derision—and feeling inferior to someone or some group often engenders criticism or derision. Doctors and surgeons must often contend with the reality that few people outside their profession can understand their experience: this general unrelatability plus hyper-accountability tendencies conspire to prevent them from sharing and asking for support in the first place—and if they do, the problem of prestige sadly decreases the likelihood of a compassionate, validating response.
The Hazards of Co-Suffering
Co-suffering is the literal Latin translation of the word compassion. Understood through this lens, compassion is clearly more than an emotional performance or an intellectual exercise: it is an active choice, or series of choices, that has a real impact on the practitioner. While gathering information for this post, a doctor who works with vulnerable, high-risk patients explained to me “the almost continuous empathy/co-suffering good doctors experience by witnessing a patient you love suffer and die is extremely trying, and can challenge us at our core.”
But the hazards of co-suffering are not only reserved for doctors and surgeons with high-mortality patients: any degree or type of healing implies some degree and type of suffering—and having to focus on physical suffering at work day in and day out can lead to feelings of cynicism or hopelessness among physicians. Furthermore, draining all reserves of compassion at work may contribute to compassion-fatigue at home: due to feeling drained and overwhelmed by the material and emotional tasks of caring for patients, physicians risk minimizing or neglecting their own medical or mental health problems—or their loved ones’.
My hope is that any physicians reading this—as well as their partners, siblings, parents, or children—who can relate to these problems, may also imagine accessing and harnessing the hidden strengths contained therein… Which I will be discussing in my next post on this topic! See you in a few weeks for your follow-up!
Janine Joly-DeMars, MS, LCMFT provides individual, couple, and family therapy in our downtown Bethesda office. Janine was recently promoted to Senior Associate, and offers daytime, evening, and weekend appointments for new and existing clients. Call or email today to set up a complimentary telephone consultation or first appointment with Janine.