Doctors burn out from a guilt that was never theirs [PODCAST]

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You feel guilty for calling in sick, taking earned vacation, or setting a boundary at work. What if that guilt was never really yours? Christie Mulholland is a palliative care physician and certified physician development coach. This episode is based on her article “Why your physician guilt may not actually be yours,” published on KevinMD. She unpacks what psychoanalyst Laurence Blum called hidden guilt, the kind that often begins in childhood and turns capable kids into compulsive achievers who feel wrong for resting. You will hear how administrators and insurance companies can step into the role an authority figure once held, and why that quietly fuels burnout. Christie also shares how she helps physicians question where the guilt comes from, and the small first steps, from using all your PTO to weighing a part-time role or sabbatical. Press play to learn how to tell whether your guilt is real or inherited, and what to do the next time it shows up.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Christie Mulholland. She’s a palliative care physician and certified physician development coach. Today’s KevinMD article is “Why your physician guilt may not actually be yours.” Christie, welcome back to the show.

Christie Mulholland: It’s a pleasure to be back. I always enjoy spending time with you.

Kevin Pho: All right. So tell us what your latest article is about.

Christie Mulholland: My latest article is about something called hidden guilt, which I think we can talk about in more depth, but it’s a term that a psychiatrist and psychoanalyst named Laurence Blum coined, and it’s really about the guilt that physicians carry. It’s not the kind of guilt that comes from making a mistake with a patient. It’s guilt that’s very old, and for a lot of us it originates in childhood. Sometimes it shows up when we’re practicing as physicians, and sometimes the system exploits that. So that’s what this article is about.

Kevin Pho: All right. So let’s go into more detail. What kind of scenarios would make physicians typically feel this hidden guilt?

Christie Mulholland: So I’ve seen it, and once you start looking for it, you see it all the time. But with physicians that I’ve worked with, it’s feeling guilty about doing something that’s actually the right thing to do, feeling guilty about calling out sick, right? We’re not supposed to go to work when we’re sick, but we do feel guilty when that happens. Guilt that comes with setting any kind of boundary with a patient, or with your workplace. Guilt about taking your vacation time that you’ve earned.

So this is the guilt that I’m talking about. It’s different than the guilt that you might naturally feel if you make a mistake or you miss a diagnosis for a patient and there’s a bad outcome. But this is guilt that isn’t necessarily rational, and it’s not proportionate to the current situation.

Kevin Pho: Now, what you describe, I’m sure, is very common for a lot of physicians, right? Just calling in sick or setting any type of boundaries. Yet it’s something that, as you as a coach and what we do on a podcast, is something that we implore more physicians to do, right? Set those boundaries, because if we don’t set those boundaries, that’s one of the reasons why physicians feel that they lose autonomy and are so, so burned out.

Now, what are some of the reasons why physicians feel guilty about something like taking a day off? Because if you look at other professions, there are no qualms about taking days off when you’re sick. But in the medical profession, it’s still very difficult to do so. Why is that?

Christie Mulholland: Right. So I’ll start deep and I’ll go back farther, and then I’ll move us to the present day. A lot of physicians, and this might not apply to everyone, but a lot of us, as children, we experience some limitations of our parents.

In my case, my story is that I grew up with an alcoholic father, and eventually he was in recovery. He was a great dad. But in some of those early memories he fell short, and as a child, a kind of natural and developmentally appropriate reaction is that you look for the reason why your parent’s shortcoming is your own fault. And you internalize that, and you develop a strong drive to become a fixer and a problem solver, not only because you want to make your parent feel better, but because you want to try to control that situation so that you aren’t disappointed again. And you feel that if you can just be good enough, do enough, achieve enough, then you can fix everything.

And so this is common among physicians, and we become compulsive achievers, and there’s a positive side to that. It takes us very far in life. For me, it took me all the way through medical school and training and to becoming a doctor. There’s nothing inherently wrong with wanting to do good and serve and help people.

But when it’s coming from a place of a wounded child, sometimes it shows up as just not wanting to get in trouble, imagining that you deserve some kind of punishment and that that punishment might come from an authority figure. And in medicine, the system becomes that authority figure that calls the shots. And when it is an insurance company trying to deny a needed treatment, or an administrator telling you to take care of the patients when you don’t have the adequate resources or staffing, that hidden guilt can become activated.

And rather than setting the boundary or saying, “This is wrong and I won’t do it,” if you are being driven by that hidden guilt from childhood, you might not actually do what’s best for yourself or for the patient when you’re trying to appease that authority figure that’s the system. And so through our training to become doctors, and through practicing for some years as physicians, the system can tend to continue re-emphasizing and inculcating that message that, yes, you should feel guilty for setting a boundary, because when doctors don’t set any boundaries and just keep on getting the job done, no matter how unreasonable the ask is, the system benefits, and not physicians and not patients.

Kevin Pho: One of the things that you wrote was very interesting. You said that medicine doesn’t necessarily create this guilt, but recruits for it, right? So physicians almost self-select to go into medicine, or physicians that have a tendency toward hidden guilt tend to go into medicine, and medicine maybe subconsciously chooses those who are predisposed to hidden guilt into the medical field, right?

Christie Mulholland: That’s exactly right, and I can’t take credit for that idea, and it’s so smart and I think so true. Laurence Blum wrote about that in his article about hidden guilt among physicians. And actually, it was a dear friend of mine who’s a private practice psychiatrist who sent me his article and said, “You really need to know about this for your coaching with doctors because it’s so true.”

Kevin Pho: So if this hidden guilt isn’t addressed, and obviously we’re talking about it, we’re naming it here, and that’s going to be the first step, of course, for a lot of physicians to address it. But assuming there are some physicians who don’t listen to you or aren’t listening to this podcast or reading your article on KevinMD, and this hidden guilt goes unaddressed, what is a typical path for these physicians?

Christie Mulholland: Well, I think it’s a path straight to burnout for a lot of us, because again, when we’re responding to hidden guilt, we’re not necessarily making the right decisions to take care of ourselves, to get enough rest. We try to just run on fumes. And of course, burnout and exhaustion lead to all kinds of bad outcomes for patients and for society, right? We’re more likely to make errors in our patient care, and we’re less likely to stand up for making the system better.

When we’re driven by guilt, again, we’re trying to appease the people that we see as being in charge rather than listening to what we know is right. So when we don’t stand up for what’s right in the health care system, then the system doesn’t have to change. So I think that, as you said, that first step for a lot of us is recognizing the guilt for what it is and not letting it drive our decisions and our actions, doing the right thing to take care of ourselves, and advocating for the change that’s needed in the system.

Kevin Pho: And even in your article, because you wrote that hidden guilt, as we talked about, sometimes starts in childhood, and one of the things that you wrote is that administrators and insurers sometimes inherit what you call the psychological authority of our parents, right? So that psychological trauma from way back when, when we were all kids, that can sometimes progress in a through line to the authority figures that doctors face today, the administrators and insurers.

Christie Mulholland: Absolutely. We’re so ingrained, and it’s so familiar to us to operate that way. We love getting that gold star. And we sometimes come to depend on someone else’s authority to give us validation that we’re doing a good job, and we don’t always develop a strong sense of ourselves to give ourselves the validation when we do the right thing.

Kevin Pho: So take us into one of your coaching sessions, because I’m going to assume that this is a pretty common scenario with a lot of physicians that you talk to. What are some of your approaches to break that pattern of hidden guilt? How do you do it in your coaching sessions?

Christie Mulholland: So I am bringing my own experience going through psychoanalysis, although I’ll start by saying there’s definitely a distinction between therapy or psychoanalysis and coaching. And I’m not qualified to do psychoanalysis. But I do bring my experience, and what that brings to my coaching approach is just a deep way of listening.

So as a coach, all of us who are coaching, we really value what’s called coaching presence. And it is just that. It is listening and approaching your client with curiosity. Listening to what they’re saying, but also trying to listen for what’s underneath what they’re saying. And for me, when it comes to something like hidden guilt or something else that seems to be coming from their unconscious mind, my antenna is up, and I’m just listening for something that doesn’t quite sound true or doesn’t quite sound matched to the reality.

So that’s the first part of my approach: listening for it. And then I’m that outside, unbiased person that can interrogate. Oftentimes my client is saying something that they assume to be true, and it’s been true their whole life, so they don’t even question whether what they’re saying is true, but it’s actually false. And so I’m that outside person that can interrogate with curiosity. Where is that coming from? Who told you that story? Whose voice are you hearing that in?

And if we are able to figure out that there’s hidden guilt that’s driving it, the next part is to bring it to awareness. Because if it stays in the unconscious, you can’t do anything with it. But when you can bring it to the level of awareness, then as a coach, I’m ready to help my client turn that awareness into action and into a next step. So that’s the general process. And then I have some activities with more structure to try and hopefully get my clients through that process I described.

Kevin Pho: So when you say take some action once it’s recognized, what are some of the activities or what are some of the paths that physicians could take to address this once they recognize it?

Christie Mulholland: Yeah, I think for taking action, we always try to start with smaller actions first, so that you can build some muscle and build some confidence. But I think going back to the example of taking your PTO, right? You’ve now recognized that by not taking it, you’re actually responding to some guilty feeling that came out of nowhere, and you’re not making the best choice. So let’s practice by using all your vacation days this year. That might be one example. I’m always looking to empower people to take the smaller actions first that might feel less scary and less intimidating.

Kevin Pho: Now, one of the things that you mention is going part-time, and we’ve talked about this also, taking a sabbatical. Sometimes going part-time is the answer for a lot of physicians to relieve their burnout, but it triggers the most guilt, right? So how do you encourage physicians to go part-time if that’s really what’s in their best interest?

Christie Mulholland: Well, that’s a big one. And of course, I’m not giving advice when I’m in the coaching role, but what’s happening with clients is they’re coming to their own conclusions about what they want and need. And my job is to, of course, validate and support them in that.

And if going part-time is the right decision, then there are a few dimensions to tease out. When it comes to taking a sabbatical, and probably going part-time too, I like to think about the financial, professional, and emotional readiness. And there are lots of concrete steps to go through to ensure that you are ready to take that step of going part-time. And when someone is able to address all of the practical steps of that, then if they’re still not ready, of course, we have to get through whatever emotional block is happening.

I have activities for each category, right? There’s the financial planning dimension. How do you make sure that you’re ready to take a sabbatical or go part-time? There are all the professional steps of planning a break. If you might come back from medicine, how do you find out what your state medical board requires if you would need to stay clinically active enough to eventually go back to practicing? And then emotional. There are some conversations that you have to have along the way. Conversations to make sure your relationships are healthy and you have a strong support system at home. Conversations with your bosses if you’re preparing to negotiate a part-time role or negotiate that break or even resign.

So I think there’s the nuts and bolts of it and making sure that all of the practical factors are addressed, and then there’s the overarching role that I see as a coach, which is just being that outside perspective to tell them that whatever they’re feeling and what they’re deciding is OK.

Kevin Pho: We’re talking to Christie Mulholland, palliative care physician and certified physician development coach. Today’s KevinMD article is “Why your physician guilt may not actually be yours.” Christie, as always, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Christie Mulholland: So I’d love for your listeners to file this information away, and the next time you feel guilty about doing something, take that as a signal to pause, not to just obey or to push through the guilt, but to actually pause, get curious about the guilt, and ask yourself a few questions. Where does the guilt come from? Is it connected to the current situation? Is it proportionate? Is it accurate? Am I actually doing something wrong, or is this hidden guilt from childhood showing up uninvited?

Kevin Pho: Christie, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Christie Mulholland: Thank you so much for having me.

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