Most accounts of physician burnout begin with a familiar list: too many hours, too many clicks, too many patients, and not enough time. The diagnosis follows easily. Doctors are exhausted. Something inside them has been used up. Burned out. That explanation has the advantage of being familiar. It also has the potential to be incomplete. There is another way to understand what is happening, one that comes from an unlikely place.

In the 1970s, a psychoanalyst named Heinz Kohut proposed that psychological distress is not always best understood as a problem within the individual. Sometimes it reflects a failure in the environment that is meant to sustain the person. Kohut was interested in something deceptively simple: how people remain themselves over time, not just functioning or performing, but experiencing their actions as continuous with who they understand themselves to be. He argued that this depends on a set of largely invisible supports, ways in which the professional world responds to us and, in doing so, stabilizes us.

He described these supports in three ways:

• Mirroring: the sense that what you do is seen and carries meaning.
• Idealization: the ability to rely on something larger, stable, and coherent.
• Twinship: the experience of working among others who share your way of being.

These are what allow a professional identity to hold together over time.

The gradual erosion of professional identity

Historically, medicine, like most professions, provided enough of this structure to sustain physicians. Clinical judgment carried weight. Institutions, though imperfect, could be relied upon. Colleagues were not just coworkers but recognizable participants in a shared role. It is harder to say that now.

A treatment plan may require approval from someone who will never meet the patient. Authorizations delay care, though responsibility for those delays is diffuse. Documentation expands, but not in ways that clarify thinking or improve decisions. Appeals sometimes succeed, but without explanation. Processes accumulate where professional dialogue once occurred. None of this is surprising in isolation. Each step can be justified. But taken together, these changes begin to alter the conditions under which physicians practice in ways that are difficult to name, yet deeply felt.

Kohut would likely have recognized the pattern, not simply as inefficiency or administrative burden, but as a gradual weakening of the conditions that allow physicians to experience their work as aligned with who they are.

• If clinical judgment is repeatedly mediated, does it still feel like your own?
• If the system cannot be relied upon, what anchors decision-making?
• If everyone navigates these constraints individually, what becomes of a shared professional identity?

These questions accumulate quietly. Over time, physicians learn where effort is likely to matter and where it is not. They adjust, not out of indifference, but out of repeated exposure to conditions that shape what is possible. Decisions are made with the system in mind alongside the patient in front of them. What begins as adaptation gradually becomes routine.

When burnout is not just exhaustion

Something else shifts as well, though it is less visible. Engagement becomes more selective. Points that once felt essential are weighed against whether they will meaningfully change an outcome. From the outside, this may resemble disengagement. From the inside, it reflects ongoing recalibration. Burnout, from this perspective, begins to look different. Although it is traditionally described in terms of exhaustion, cynicism, or detachment, that language does not fully capture what many physicians describe when they are candid:

• “This is not how I expected to practice.”
• “I spend more time navigating the system than caring for patients.”
• “I am not sure what kind of physician this is shaping me to be.”

The work continues. Patients are seen. Tasks are completed. Nothing has obviously failed. Yet a subtle misalignment can emerge between the physician and the conditions of practice. A person can tolerate significant difficulty if their work still feels like a coherent expression of who they are. When that coherence weakens, something more fundamental is affected. The physician remains. The role remains. But the connection between them becomes less stable.

Rethinking our response to physician burnout

This helps explain why many responses to burnout feel incomplete. If the problem is framed as stress, the solution becomes stress management. If it is framed as fatigue, the response is rest. If it is framed as a lack of resilience, the response is training. Each has value, but none address whether the environment still supports a meaningful alignment between physician and practice.

Kohut did not write about health care systems. But his framework points in a clear direction. If physicians are to remain present in their work, the structure of that work must meet them in specific ways. It must reflect their judgment as meaningful. It must be sufficiently stable to rely upon. It must allow for a sense of shared professional identity rather than isolated adaptation.

Without these conditions, physicians do not necessarily stop working. They continue, often competently, even exceptionally. But over time, the work draws on a narrower and narrower portion of who they are. If burnout is understood in this way, it will not be resolved by asking physicians to better endure conditions that steadily narrow their role. It will require attention to the conditions themselves: how work is structured, how decisions are mediated, and whether the practice of medicine still allows physicians to experience what they do as a coherent extension of who they are.

The work will continue with diminishing alignment between the physician and the practice of medicine, or, more simply, with less and less of themselves.

Timothy Lesaca is a psychiatrist in private practice at New Directions Mental Health in Pittsburgh, Pennsylvania, with more than forty years of experience treating children, adolescents, and adults across outpatient, inpatient, and community mental health settings. He has published in peer-reviewed and professional venues including the Patient Experience Journal, Psychiatric Times, the Allegheny County Medical Society Bulletin, and other clinical journals, with work addressing topics such as open-access scheduling, Landau-Kleffner syndrome, physician suicide, and the dynamics of contemporary medical practice. His recent writing examines issues of identity, ethical complexity, and patient–clinician relationships in modern health care. Additional information about his clinical practice and professional work is available on his website, timothylesacamd.com. His professional profile also appears on his ResearchGate profile, where further publications and details may be found.