Physician Well-Being and Coping With the Rigors of Psychiatric Practice

Frequent Encounters With Distress

Psychiatrists encounter human suffering every day. The nature of psychiatric practice is that clinicians witness countless stories of sadness, anger, and betrayal. Although moments of joy and happiness arise, they often seem few and far between. The chronic and devastating nature of many psychiatric diseases increases the emotional burden on the clinician. Psychiatrists must remain emotionally available to their patients to experience and express the empathy that is necessary for forming an alliance—this emotional availability can make psychiatrists particularly vulnerable to suffering alongside their patients. Psychiatrists must strike a critical balance between emotional availability, while still maintaining enough distance to remain objective.

While encounters with suffering may increase stress, interpersonal connections with patients may also be protective. Bearing witness to distress, maintaining empathy, and establishing humanistic connections may even be protective against depersonalization, a characteristic of burnout. Depersonalization describes a dehumanization and detachment from our patients, which in the short term might be protective for the physician, but in the long run may detract from the rewards of the profession.

Ethical Dilemmas

The patient's reliance on the psychiatrist for guidance can raise a host of ethical conflicts. Psychiatrists can find themselves watching their patients make unwise, and even dangerous, decisions and being unable to curtail this destructive behavior. Psychiatrists might have to enforce mandated treatment regimens, to hospitalize patients against their will, or even to physically restrain violent patients. There may even be times when psychiatrists must intentionally break patients' confidentiality for their safety or for the safety of others. None of these decisions is made lightly, and each requires a great deal of reflection and emotional energy.

Transference and Countertransference

The daily practice of psychiatry is filled with issues of transference and countertransference, leading to the development of intense emotions (e.g., hostility, aggression, love) in the patient and the clinician. Furthermore, several psychiatric illnesses have, as core symptoms, difficulty with interpersonal interactions. Afflicted patients, including those with borderline personality disorder and narcissistic personality disorder, can pose a special challenge. Coping with intense transference, while monitoring one's own countertransference, can be exhausting; it is a daily challenge for most psychiatrists.

The Perception of Failure

Psychiatrists treat chronic illnesses, which are subject to relapse and carry significant morbidity and mortality; thus, the very nature of psychiatric disease can lead the psychiatrist to experience feelings of failure as a doctor and a healer. Despite knowledge of treatment–response rates, psychiatrists might believe that if they could only find the right medication or say the right words, the patient would be healed. Failure to respond to treatment can be, and often is, viewed as a failure of not only the medical intervention, but also the treater. Vulnerable psychiatrists may then question the purpose and meaning of their work.

Bearing the Burden of Stigma

Psychiatry and its practitioners are under intense public scrutiny. Psychiatric treatment, medications, and research have been called into question by the media, the government, and even popular culture icons. Whereas psychiatric successes take place behind closed doors, treatment failures have grown increasingly public and fuel stigma of mental illness. This public criticism can be disheartening and can make it difficult to maintain meaning in one's work.

Controlling Affect

Despite the intensely emotional nature of psychiatric work, psychiatrists must consistently control their affect to do their jobs well. Although this control is necessary for the practice of psychiatry, it can ultimately lead to increased stress and vulnerability to burnout. Instead, informal processing with colleagues, or formal supervision, can encourage the necessary expression of what is controlled during patient encounters.

Responsibility and Uncertainty

The practice of psychiatry is multi-dimensional, and it incorporates interpersonal and individual dynamics, sociology, biology, and pharmacology. The complex nature of psychiatry makes it an exhilarating, yet uncertain field. Although the breadth and depth of psychiatric research are growing exponentially, there is still a dearth of research to guide many clinical decisions; psychiatrists must often base clinical decisions on biased, incomplete, or ambiguous data. These challenges are further compounded by the added stress of answering to institutions, insurers, patients, and their families. Health insurance organizations often establish standards of care without involvement of psychiatrists, which can undermine the self-determination of practitioners. Psychiatrists can find themselves in the difficult position of not being able to provide the treatment they believe is best, due to systems' limitations.

Disruption of Social Relationships

Psychiatrists often work in isolation, leaving them alone to face the effects of psychopathology and disease. Furthermore, rules regarding confidentiality inhibit sharing the details of one's day with family and friends. Social engagements and family time can be interrupted (without warning) by emergencies. These factors can fracture social relationships, decrease social support, and increase the risk of burnout. Thus, it is important for psychiatrists to develop robust and diverse support systems—professionally, for the necessary debriefing of clinical challenges, and personally, for the maintenance of well-being outside of the practice environment.

Delayed Gratification

The ability to delay gratification is an important developmental milestone. The practice of medicine raises it to an art form. But this skill, when taken to an extreme, can lead to burnout. Physicians may be tempted to put personal goals on hold, in the service of career success (e.g., “I can't get married, have children, or buy a house until I have a stable practice.”). Such rationalizations can be extended indefinitely and lead to a life lacking balance and devoid of non-vocational success.

Being the Caregiver

Physicians have a strong need to be needed and to care for others. These traits are part of what initially draws individuals to the practice of medicine. At the same time, the dependence some patients develop on their psychiatrists can be overwhelming in its intensity. Focusing intently on the needs of others can lead to denial of one's own need to be cared for.

Financial Stress

Although the popular perception is that doctors make copious amounts of money, the reality is quite different. The cost of medical education can be exorbitant, and it continues to rise each year; however, physician salaries do not enjoy the same growth, and the increases in earnings over time might not even match the rate of inflation. Many young doctors finish residency with enormous debt and have limited options for repayment and deferment of loans. Furthermore, the practical options for improving one's financial situation are limited to working longer hours or seeing more patients (for shorter periods of time). Either option is likely to increase, rather than to decrease, vocational stress; this pressure may be especially intense for physicians early in their careers.

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