Psychiatrist who specializes in treating physicians says they often “disown their inner experiences”

For the past 18 years she has been a consultant with the OMA’s Physician Health Program, and for the past decade has focused her private psychiatric practice primarily on treating physicians. When she accepted a Community Advocacy Award from the Ontario Psychiatric Association, for her work as a PHP treater, she said, “So many doctors find themselves feeling alienated – working, striving, seemingly alone. So there is incredible relief and appreciation in being seen and heard.”

Dr. Dorian has devoted her life’s work to mental health. At the Toronto General Hospital, she was part of a team providing psychiatric care to medically ill patients and those undergoing lung transplants. There, she explored eating disorders and the link between stress and immune function. She later joined Mount Sinai Hospital to participate in clinical research on psychological treatments for women undergoing treatment for breast cancer.

Women’s College Hospital then recruited her to be chief of psychiatry. At the Clarke Institute of Psychiatry, now the Centre for Addiction and Mental Health, she also helped develop an inpatient unit for women and, with Women’s College, a program to help women recovering from abuse.

In a conversation with the Ontario Medical Review, Dr. Dorian shares how physicians can struggle with their mental health and the toll it can take on their personal and professional lives.

OMR: Is there a difference in creating a doctor-patient relationship when you’re treating physicians?

Dr. Dorian: One of the keys when you’re involved in a psychotherapy relationship with a patient, a physician, in this case, is that the first step is to establish rapport. There’s something satisfying about the fact that we have an implicit knowledge of the experience of becoming a physician, being a physician and practising medicine. People have to trust us enough to take us into their inner life. Having some of that intuitive knowledge of the physician experience is helpful in setting the stage for that. What’s important after that, though, is to move to finding that unique individual person inside the doctor.

OMR: Do you see commonalities in physicians’ struggles?

Dr. Dorian: Physicians in general have a lot of similar characteristics. They tend to be ambitious, hard-driving, highly conscientious and socially responsible. And actually, a bit neurotic, especially in the ways of self-criticism, self-doubt and anxiety – being concerned about doing the right thing, making the right diagnosis and functioning at a high level. Huge achievement motivations make for very good doctors. But when all those good things become too much of a good thing, they start to backfire. And so you see people preoccupied with perfectionism, exhausted by the emotional energy it takes to be so vigilant all the time.

A lot of medical work also runs on the fear of not doing enough. We see the “heroic caretaker” working relentlessly, while barely treading water themselves. Physicians can become overwhelmed by the very qualities they value and aspire to.

OMR: Is that what leads to burnout?

Dr. Dorian: It’s a piece of the predisposition to burnout. But I take issue with the idea that physicians can cope with burnout and avoid burn-up by becoming more resilient. Physicians are some of the most resilient people there can be. If you can get through 15 years after high school, of education, exams, resident training, etc., you’re a very resilient person.

The issues that are currently creating so much burnout have to do with the exponential demands for clinical care, especially through the pandemic, and a whole lot of institutional drivers. The problems that doctors are facing are primarily related to issues in a fragmented health-care system, and shifts in institutional policy and organization over time. Doctors are spending so much less time doing what they are trained to do. They’re faced with mountains of paperwork and the EMR, which is so time consuming and draining. So you have these highly trained people, who want and need to be treating patients, and they are starting to feel like clerks.

For any of us, if we’re exhausted, if we’re feeling the demands of our work are much more than we can cope with, we’re not going to be effective. We’re not going to be good team members. We’re not going to be good collaborators. We’re obviously not going to be good for our families and the rest of our interpersonal world. For physicians, the stakes feel very high.

OMR: Some patients might be troubled if they knew their physician was seeking psychiatric help. What would you say to anyone who had those concerns?  

Dr. Dorian: The medical culture has not moved all that far in terms of the stigma around mental health. Physicians prize their ability to function, be effective and perform. If they feel they’re not able to do that and have any kind of “incapacity,” as they might label it, they have a tendency to feel ashamed.

I think if the physician can believe and say to their patient, with confidence, ‘I’m a human being, I have needs, conflicts and emotions the same as everyone else, and I feel it’s a sign of strength and courage to get help for that, and I hope you would feel the same if you were in that situation’ – that’s a way of conveying this is a positive thing. Studies show that many physicians function well while they’re in therapy and undergoing treatment and there’s no reason, except in exceptional cases, why they shouldn’t.

OMR: What advice would you give to physicians who may be struggling in today’s stressful environment?

Dr. Dorian: There’s a recent study of 2,000 physicians. Eighty per cent of them said they go to work while they are ill because otherwise, they feel negligent or self-indulgent. Changing that belief system is critical to the goal of work-life balance.

Also, an underlying theme in what we’re talking about is that often physicians don’t know themselves well. Their extensive training may subvert some of their emotional and interpersonal development. And then through the practice of medicine, one of the things that one must do to a certain extent is wall oneself off from the extremes of emotional burden. Physicians learn to disown their own inner experiences. So going through the process of the PHP, which is a lot of self-exploration, does open people to feel greater joy and appreciation in their everyday lives and in the practice of medicine.

OMR: What would you tell other physicians who are considering becoming a PHP treater?

Dr. Dorian: Don’t be frightened of it. So many physicians have avoided it because of the same characteristics we’re talking about. They fear making mistakes. They fear, in particular, the judgment of their colleagues. The person you’re treating might become critical of your manner, interventions or knowledge.

Have confidence in your competence, and know the PHP is there for support. See your knowledge of the physician’s experience as a benefit, and at the same time encourage the physician patient to leave the white coat at the door. When you do that, as long as you maintain boundaries, it becomes extremely rewarding. There is a special feeling of caring for and protecting your troops – your professional family – and doing something for the system, too. Because now this doctor can go on to a fulfilling career, and in their career, they will help many, many people.

This interview has been edited for length.

Editor’s note: This story has been updated to reflect that the former Clarke Institute of Psychiatry is now known as the Centre for Addiction and Mental Health. The Ontario Medical Review regrets the error.

Stuart Foxman is a Toronto-based writer.