Helping everyone but yourself: doctors as patients

“I know what it is. Tiredness. Nothing special.”

This is said by a doctor who, for the third month now, has been sleeping four hours a night, wakes in the morning with a pounding heart and has started closing the door between two patients at the surgery so he can rest his head on the desk for a minute. To a patient with the same symptoms he would say, without hesitation, to get checked, to take sick leave, to find help. To himself he says, “It’ll pass.” And he writes himself a prescription for a sleeping pill that he otherwise prescribes with great caution.

This is not an invented quirk of one person. It is a pattern described by research around the world and well known to those who work with doctors. People who spend all day looking after the health of others are often the last to look after their own. In this post I want to write about why this happens, what we know about it — and where a doctor can turn when they realise that now it is they who need help.

Although I am writing mainly about doctors, lawyers, investment bankers and others who work in professions where you have to be strong all the time will recognise themselves in much of this.

Why it is so hard for a doctor to be a patient

Being a patient means admitting something: that you cannot manage something on your own, that you do not know everything, that you depend on someone else. For most people this is uncomfortable. For a doctor it is often almost impossible, because it runs against everything the profession has taught them about who they are.

Already during their studies, young doctors learn that distress has to be put aside. That you do not cry during resuscitation. That after a patient dies, you move on to the next one. In the moment this is necessary — anyone who stopped at every difficult event could not work. But when this ability spreads to the whole of life, a problem arises. The doctor learns that their emotions and body are an obstacle to be overcome, not a message to be heard.

As early as 1985, the psychiatrist Glen Gabbard described this as the compulsive triad typical of many doctors: doubt, feelings of guilt and an exaggerated sense of responsibility. These traits make a good doctor. But these same traits prevent them from allowing themselves rest or help — because it would mean “letting down” patients and colleagues. I write about how precision in such professions spills over into fear in the post Perfectionism in professions where mistakes are not allowed.

What we know about burnout in doctors

The most frequently cited research on burnout among doctors comes from the United States, above all from the group around Tait Shanafelt. In a large study published in 2015, 54 per cent of the American doctors who took part reported at least one sign of burnout — emotional exhaustion or detachment from patients. The proportion was higher than three years earlier and higher than among other working people in the US.

You have to be careful with these figures. The healthcare system in the US is different from ours, the measures of burnout differ between studies, and surveys only ever capture those who responded. So I do not transfer these percentages to Slovenia. What does repeat in research from different countries, however, is the direction: burnout among doctors is common, often more common than in the general population, and it is not only a matter of individual resilience but also of how work is organised.

Burnout is not a doctor’s private affair. A 2018 meta-analysis by Maria Panagioti and colleagues showed that doctors’ burnout is associated with more patient safety incidents, less professional conduct and lower patient satisfaction. This does not mean that a burnt-out doctor is a bad doctor. It means that caring for doctors is not a luxury but part of caring for patients.

“I would never want that on my record”

One of the most common barriers is the fear of what it will mean if a doctor becomes a patient because of psychological distress. In an American survey of female physicians published in 2016 by Katherine Gold and colleagues, many respondents said they had had difficulties worth treating but had not sought help — and among the reasons they often cited the fear that a diagnosis would remain on record. The title of the article says it all: “I would never want to have a mental health diagnosis on my record.”

In 2017, Liselotte Dyrbye and colleagues showed that doctors in those US states where medical licence renewal forms ask about mental health were more often reluctant to seek help. I will not guess how this works here — rules and practices differ from country to country, and it is best to ask the relevant institutions or a lawyer about what applies in Slovenia. But something else matters: the fear itself, whether or not it is justified, keeps people away from help.

It may help to know how confidentiality in therapy works: what stays between therapist and client and where its limits lie. Before the first session you are free to ask the therapist about this directly — it is a perfectly ordinary question.

Self-treatment and corridor consultations

A doctor has access to knowledge and often to medication as well. So the temptation to treat yourself is strong. A sleeping pill for difficult nights. A glass or two to unwind after a night shift. A sedative before an important procedure. None of this is necessarily dramatic. But when it becomes the only way a person copes, help often turns into a new problem.

Another form is what doctors themselves call a “corridor consultation”. You briefly ask a colleague for an opinion, they recommend a test or a medicine, and the matter seems to be settled. What is missing is what any other patient would get: a full assessment, someone who guides you through the process, and a space where you are allowed to be just a patient, not a colleague. I write about how professionals actually find their way to help in the post Who heals the healers: how professionals look for help.

A helper who does not know how to receive

In relational family therapy, in which I am training, we often ask how a person grew up in the role they now play in life. Among people who choose the helping professions, it is not unusual for them to have looked after others as children. A mother who was often sad. Younger brothers and sisters. The peace in the family. They learned that they matter when they are useful — and that their own needs come last.

Of course this does not apply to every doctor, and it is not a precondition for doing the job well. But when it is the case, the problem runs deeper than tiredness. The person does not know how to receive. When someone offers help, they feel uneasy, sometimes even ashamed. It is easier for them to care for ten others than to let someone care for them. I describe a similar dynamic in the post Men and therapy: why they come later and what stops them — there, too, it is often about the belief that you have to endure everything alone.

The family feels the consequences as well. A doctor’s partner often says that they live with someone who is available to everyone else, but no longer to them. Children learn not to disturb their father or mother, because they are “tired from patients”. And the doctor feels that everyone needs something from them, yet nobody sees them.

A conversation many people know

This is how a conversation between a doctor and her partner might sound (composite, not a real person):

“You haven’t slept for three weeks. When are you going to see someone?”
“See whom? I know everyone. They’d all know who I am.”
“So what?”
“Then they’d know I can’t cope.”
“Or they’d know you’re human.”

In this short exchange all the barriers appear at once: the fear of being exposed, the belief that distress means incompetence, and a small but important opening offered by someone close. Often it is precisely the partner who first says out loud what the doctor has known for a long time.

Lawyers and bankers: the same story in different clothes

With lawyers and investment bankers the content is different, but the mechanism is similar. Here, too, the profession is built on the image of someone who can cope. A lawyer has to appear assured before a client and a court. A banker must not show uncertainty in front of a client who has entrusted them with millions. If you spend the whole day as the one who knows, it is hard to become, in the evening, the one who does not.

Self-treatment is common here as well: with alcohol at business dinners, with coffee and other stimulants, with work itself. So is the belief that distress is something to hide, or it will affect promotion. I am not claiming this is true in every office or bank. I am claiming that this fear keeps people silent for longer than is good for them.

An exercise for today: take your own history

This exercise makes use of something a doctor knows how to do very well: take a history. Only this time you take it from yourself. If you are not a doctor, you can do it too — the questions are simply yours.

1. Take a sheet of paper and write “Patient: X, aged …” and fill in your age. Write in the third person, as if it were about someone else.
2. Write down the last three months: how many hours a night they sleep, how they feel in the morning, how much they drink, whether they take anything to sleep or to wake up, when they last had a free weekend.
3. Write down what the people close to them say. Has a partner or friend ever said something that the “patient” brushed aside?
4. Read what you have written as if it had been brought in by someone you do not know. What would you advise them? What would you write under “recommendations”?
5. Choose one recommendation and act on it this week. Book an appointment with your own GP, call someone you trust, or look for a therapist. Not everything at once — one thing.

Many people are surprised to discover during this exercise that they would advise a patient with such a history to seek help without a second thought. The gap between what you would tell someone else and what you tell yourself is important information in itself.

Where this explanation does not apply

I would not want to give the impression that all doctors are burnt out or that none of them knows how to seek help. Many doctors have good support — in their families, among colleagues, in supervision groups or in their own therapy — and do their work with satisfaction even after decades. Research on burnout measures averages, not the fates of individuals.

Nor is everything I describe a matter of personal psychology. When a doctor works in a system with too few staff, long on-call shifts and ever more paperwork, their exhaustion is a response to conditions, not a sign of personal weakness. In a 2018 review, Colin West, Liselotte Dyrbye and Tait Shanafelt emphasise that the most effective measures are those that combine support for the individual with changes in the organisation. Therapy can help a person not to carry everything alone, but it cannot replace a reasonable rota.

And finally, perhaps most importantly: when it comes to severe depression, intense anxiety, addiction or thoughts of suicide, therapy is not the first step. Then it is right to turn first to your GP or a psychiatrist. I write more about this in the post When you need a psychiatrist first: signs that therapy is not the first step. A 2004 meta-analysis by Eva Schernhammer and Graham Colditz showed that the risk of suicide among doctors is higher than in the general population, especially among female doctors. If you ever think it would be better if you were not here, call the crisis line Klic v duševni stiski on 01 520 99 00 in Slovenia (every day from 7 pm to 7 am) or the Samaritans helpline Samarijan on 116 123 in Slovenia (24 hours a day). In an emergency, call 112.

Where to turn for help

The first step is often the simplest and at the same time the hardest: a doctor has a GP too, and can turn to them like any other patient. It may help to say, when booking, that you want to be treated as a patient, not as a colleague. When an assessment of medication or a diagnosis is needed, a psychiatrist is the right path. But when it is about exhaustion, patterns in relationships, the feeling that it is never enough, or distress you have been carrying for a long time, psychotherapy can help. I explain the difference between these roles in more detail in the post Psychotherapist, psychologist, psychiatrist: who does what and where to go.

My sessions take place in person, in Ljubljana, and I also work with English-speaking clients. For someone who spends the whole day on the side of the one who helps, simply sitting on the other side is an important step. In therapy you do not need to know the answers, you do not need a diagnosis and you do not need to be a colleague. You can simply be a person who is tired. If you would first like to check for yourself where you stand, the burnout self-check tool in the knowledge base may help.

What to remember

• Doctors often seek help late — because of stigma, fear for their reputation, self-treatment and a sense of guilt towards colleagues.
• In a US study from 2015, more than half of doctors reported at least one sign of burnout; the figures cannot be transferred directly elsewhere, but the direction repeats.
• A doctor’s burnout is not a private matter: it is also linked to patient safety.
• The gap between what you would advise a patient and what you tell yourself is important information.
• With severe depression, addiction or thoughts of suicide, the first step is a doctor or psychiatrist; therapy can come alongside or later.