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Physician Work Environment and Well-Being
April 8, 2019

Physicians’ Goodness and Guilt—Emotional Challenges of Practicing Medicine

Author Affiliations
  • 1Independent Private Practice, Philadelphia, Pennsylvania
  • 2Department of Anthropology, University of Pennsylvania, Philadelphia
  • 3Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 4Psychoanalytic Center of Philadelphia, Philadelphia, Pennsylvania
JAMA Intern Med. 2019;179(5):607-608. doi:10.1001/jamainternmed.2019.0428

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.

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Article Information

Corresponding Author: Lawrence D. Blum, MD, Independent private practice, 2400 Chestnut St, Ste 2810, Philadelphia, PA 19103 (ldb@lawrenceblum.com).

Published Online: April 8, 2019. doi:10.1001/jamainternmed.2019.0428

Conflict of Interest Disclosures: None reported.

References
1.
Drummond  D.  Physician burnout: its origin, symptoms, and five main causes.  Fam Pract Manag. 2015;22(5):42-47.PubMedGoogle Scholar
2.
Oxford Living Dictionaries. Definition of guilt in English: guilt. https://en.oxforddictionaries.com/definition/guilt. Accessed September 23, 2018.
3.
Dictionary.com. Guilt. https://www.dictionary.com/browse/guilt. Accessed September 23, 2018.
4.
Villwock  JA, Sobin  LB, Koester  LA, Harris  TM.  Impostor syndrome and burnout among American medical students: a pilot study.  Int J Med Educ. 2016;7:364-369. doi:10.5116/ijme.5801.eac4PubMedGoogle ScholarCrossref
5.
Koven  S.  Letter to a young female physician.  N Engl J Med. 2017;376(20):1907-1909. doi:10.1056/NEJMp1702010PubMedGoogle ScholarCrossref
6.
Gabbard  GO.  The role of compulsiveness in the normal physician.  JAMA. 1985;254(20):2926-2929. doi:10.1001/jama.1985.03360200078031PubMedGoogle ScholarCrossref
7.
Lapedis  CJ.  Murky water.  Ann Intern Med. 2018;169(6):415-416. doi:10.7326/M18-1398PubMedGoogle ScholarCrossref
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    3 Comments for this article
    EXPAND ALL
    The Role of Guilt in Choosing Medicine is Questionable
    Edward Volpintesta, MD | Bethel Medical Group
    It’s hard for me to believe that guilt drove me into medicine. Everyone feels guilty about something—isn’t it part of the human condition?
    How about other more reasonable forces like wanting the prestige, or the financial security, or carrying on a family tradition, or simply being encouraged by one’s parents?
    CONFLICT OF INTEREST: None Reported
    Guilty pleasures
    Misha Denham, D.O. | Endocrine Solutions of S. FL.
    I appreciate this article and believe it is pulling the conversation about physician suicide and burnout full circle. There must be certain personality traits that drive a majority of us (physicians and surgeons) into an increasingly thankless job. Clearly self-flagellation for being a "bad" boy or girl makes sense for only a few personalities, while others may simply savor in the negative attention received. If there is a guilty personality type attracted to medicine we should be able to acknowledge it, make new medical school applicants' vulnerabilities more salient, and groom opportunities for the guilt to be recognized and released. This may dampen the current trend of "burnout" in our current medical world as we know it, and I will be more vigilant to internalize my own potential sources of guilt and expose the irrational patterns that lead to my rational path.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Has Medicine Become Too Complicated to Protect Physicians' Goodness and Save Them From Guilt?
    Edward Volpintesta, MD | Bethel Medical Group
    Has the practice of medicine become too complicated? Is there simply too much research and too much to know? Have physicians as a result become too vulnerable to error and liability?
    Do patients expect perfection from doctors?
    Does the medical liability system exploit physicians?
    If so, then regardless of how good or bad or indifferent physicians’ or medical school applicants’ personality traits may be, the emotional challenges of practicing medicine will surely increase with time.
    Is there really an answer?
    CONFLICT OF INTEREST: None Reported
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