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Physicians want to do good. Physicians also have high rates of burnout, depression, and suicide. These 2 facts are closely associated. As a psychiatrist and psychoanalyst who has treated many physicians, I have repeatedly observed that the need to do good derives in part from hidden guilt and has substantial effects on how physicians experience themselves and their work. Among the many motives for wanting to be a physician, the one that applicants to medical school most commonly mention is wanting to do good. Medical literature on physician burnout, depression, and suicide, however, has focused on structural and cultural problems of medical practice and has paid little attention to physicians’ emotional lives.1 The hidden guilt and need to do good can facilitate the practice of medicine, but they also make an important, and perhaps unrecognized, contribution to physicians’ vulnerability to burnout, depression, and suicide.
Dictionaries define the emotion of guilt as “a feeling of having committed wrong or failed in an obligation”2 or “a feeling of responsibility or remorse for some offense, crime, wrong, etc, whether real or imagined.”3 In fact, people commonly feel guilty when they have actually done nothing wrong. All sorts of experiences in childhood, such as deaths in the family, illnesses, traumas, abuse, divorce, and problematic relationships can saddle a person with an unrecognized burden of guilt. This guilt may be hidden for a long time, but then play an important role in later years. My patients who are physicians have taught me that many experience this type of irrational but powerful guilt and often find it difficult to acknowledge.
Why do physicians so seldom recognize their struggles with guilt? For starters, physicians tend to be altruistic, and doing good is one of the best protections against feeling guilty. Physicians also rely on numerous other techniques to keep guilt from awareness, one of the most common of which is worry. Many physicians worry all the time that they will miss a diagnosis, a procedure will have an unforeseen adverse effect, or they will be sued if an adverse outcome occurs. Clinical experience has shown me that such distressing worries help to direct attention away from guilt and keep it out of awareness, assuage guilt by providing evidence of conscientiousness, and diminish guilt by providing some punishment for it. The worries feel realistic (one can miss a diagnosis, procedures have risks, and there are things one does not know), so the irrational guilt-punishment-worry mechanism remains invisible. In addition, few things serve to diminish guilt better than punishment, and medical practice offers many possibilities for this in addition to worrying. Familiar ones include working endless hours, finding reasons to delay leaving the hospital, struggling to enjoy leisure time, straining to save the world at every moment, and the increasingly recognized medical impostor syndrome, in which qualified physicians berate themselves with the irrational idea that they are unqualified.4 Suzanne Koven, MD,5 has written about fighting this feeling of being a fraud her whole career. In a recent article, she acknowledged her “self-flagellation”5(p1908) but did not venture a reason for it.
One patient I treated experienced a different form of self-debasement. Having had no prior difficulty with his studies, he arrived at medical school and distracted himself, failed tests, and convinced himself that his brain was defective. When we discovered together how guilty he felt for wishes to surpass his beloved physician father, his symptoms began to abate.
As problematic and irrational as guilt can be, it is also necessary for good interpersonal relationships. It promotes important traits for physicians: responsibility, reliability, and concern and respect for others. Altruism, another important trait for physicians, often draws on childhood experiences of having been well-loved and taken care of and wanting to provide such experiences for others. But the altruistic drive to be giving and good can also draw from pressured reservoirs of hidden guilt. An adaptive way to dispel this internal pressure is to try to do good in the world, such as by the choice of medicine as a career. By comparison, I have not observed law students and business students to guiltily accuse themselves of being impostors to the extent that medical students regularly do, and fewer feel the familiar medical students’ need to do good.
The hidden guilt that can propel students into a medical career has important subsequent effects. It helps make incoming medical students a responsible, altruistic, and hard-working group. But it also sets them up for future problems. Medical students and physicians soon face life and death clinical responsibilities, many circumstances in which no good outcome is possible, inevitable errors in clinical judgment, torturous if often preposterous malpractice suits, and endless bureaucratic criticism and interference. These are all things that frustrate physicians’ efforts to do good and provide abundant opportunity for guilty self-blame. No wonder physicians struggle with burnout, depression, and suicide. Medical literature on these outcomes has focused on those factors that are external to physicians’ minds, however, and the driving role of physicians’ guilt has often been missed. (One important exception is the discussion of guilt by Glen O. Gabbard, MD, in a 1985 article, “The Role of Compulsiveness in the Normal Physician.”6)
One physician consulted me and wondered about having burnout or depression. The physician saw the problems as largely determined by workload and problematic cases. A specialist in highly technical procedures, this individual concealed a reputation for superb results. When things went well, the physician took no credit; if things went poorly, the physician insisted on self-blame, no matter how impossible the case. Each morning this individual recited a litany of self-accusations for every recollected case in which something had gone awry, a ritual self-torture that was rationalized as useful. As I helped make clear that the difficulties were internal as well as external, the physician asked what I thought the problem was. I replied, “With this much self-punishment, how about guilt?” We laughed, and the physician expressed chagrin for not thinking of that and said that a weight had lifted.
Once we acknowledge that struggles with guilt can attract people to medicine, we can expand our ability to understand how physicians deal with the inevitable strains of practice. We can also begin empirical study of the role of guilt in human minds. As physicians, we usually favor a comprehensive approach, but with respect to physician burnout and suicide prevention, the focus has been too narrow. Lapedis, reminiscing about the suicide of a medical school classmate, observed in 2018, “At the recent Association of American Medical Colleges national conference, there was a call to focus suicide and depression research initiatives on the culture, policies, and structures of our institutions of medical education rather than on individual factors related to the students themselves.”7(p416) Similarly, physician suicide and burnout prevention efforts typically address important workplace problems such as duty hours, electronic medical records, the abuses of managed care, and decreasing respect for physicians. They sensibly advocate wellness activities, such as taking time to relax or share one’s burdens. But we also need to consider who we are, why we go into medicine, and what prompts us to sacrifice ourselves in the small ways essential to good medical care and in the extreme, self-punitive ways that lead to substantial suffering, depression, and even suicide.
Physicians are educated in rational decision making. We need more help dealing with the irrational that resides in all of us. We need to accept that we all have emotional conflicts. Everyone, including patients, would benefit if medical students and physicians have opportunities to discuss their emotional challenges with their work, as well as ready access to psychotherapy and other mental health services to help address underlying emotional struggles. When physicians get help recognizing the needless guilty self-punishments often entwined with their work, they can evaluate their difficulties more realistically and derive more pleasure and less pain from their work and their lives.
Corresponding Author: Lawrence D. Blum, MD, Independent private practice, 2400 Chestnut St, Ste 2810, Philadelphia, PA 19103 (firstname.lastname@example.org).
Published Online: April 8, 2019. doi:10.1001/jamainternmed.2019.0428
Conflict of Interest Disclosures: None reported.
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Blum LD. Physicians’ Goodness and Guilt—Emotional Challenges of Practicing Medicine. JAMA Intern Med. 2019;179(5):607–608. doi:10.1001/jamainternmed.2019.0428
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