What You Need to Know When Treating Physicians: Issues, Sensitivities, and Considerations

Significance for the Practicing Psychiatrist

“Physicians make terrible patients.”

This old saying has a lot of truth to it, especially if the physician who is trying to treat a colleague is not knowledgeable about the challenges, barriers, and pitfalls involved in caring for doctors. Some of these challenges are related to personality traits and behavior patterns common among physicians, while others arise out of the culture of medicine, the socialization physicians undergo during their education and training, and today’s regulatory environment.

Although physicians come in all shapes and sizes with highly variable personalities and styles, they share some character traits. In fact, premedical and medical education and the process involved in choosing candidates for medical schools and residencies select for these traits that can make doctors difficult to treat.^1-3 They include:

• Perfectionism

• Strong work/school ethic

• Reluctance to delegate authority

• Harsh self-judgment

• Unrealistic expectations of self and others

[[{"type":"media","view_mode":"media_crop","fid":"49527","attributes":{"alt":"© alliance/shutterstock.com","class":"media-image media-image-right","id":"media_crop_893288982127","media_crop_h":"301","media_crop_image_style":"-1","media_crop_instance":"5997","media_crop_rotate":"0","media_crop_scale_h":"145","media_crop_scale_w":"100","media_crop_w":"208","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"© alliance/shutterstock.com","typeof":"foaf:Image"}}]]These traits make it difficult for the average physician to prioritize basic self-care and to seek out appropriate assistance with health maintenance activities and treatment for health-related problems when they do occur.⁴ As a result, physicians neglect routine health care; fail to notice early signs of dysfunction; or respond to such signs with minimization (“Well, my fever and cough are probably not that serious . . . ”), rationalization (“I need to get a flu shot, but I’m way too busy this week . . . month . . . year”), or externalization of blame (“My husband wants me to see a psychiatrist about my mood swings and temper outbursts, but if he would just stop nagging me about spending more time with the family, everything would be fine”).

Physicians who were fairly well compensated in past years are experiencing increased stress-related symptoms and illnesses as they struggle to cope with the changes in health care delivery. For primary care providers and many specialists, these changes mean working longer hours for less reimbursement. Increased oversight and review mean that the doctor is likely to receive feedback from multiple sources that feels like an attack on his or her competence, skills, and “bedside manner.”⁵

So the physician-patient presents to a health care provider’s office with what may seem like a simple problem, illness, or symptom complex. But he is also dragging a heavy load of unresolved emotional distress, fear, and resentment. In most cases, this burden is invisible to the provider but is paramount to the physician-patient, despite his efforts to keep it out of the conversation or examination room.

CASE VIGNETTES

Dr G is a 47-year-old family practitioner in a busy group practice. He works 65 to 70 hours every week with a night/weekend call every eighth week. He is married with 3 school-age children. His wife describes him as having had a “personality change” over the past 2 years, with unstable mood and episodes of yelling at her and the children. Last week he threw a vase across the kitchen, splashing water on the cat and frightening everyone. His wife has given him an ultimatum, stating that unless he sees a psychiatrist and gets better quickly, she is going to talk to an attorney.

He comes to see a general psychiatrist “to get my wife off my back” but denies feeling depressed or anxious; having suicidal ideation; or experiencing any physical symptoms, change in appetite, or sleep disturbance, “. . . that is when I can get any sleep if the g-damn phone quits ringing!” When the psychiatrist questions him about his relationships with his children, he begins to cry and says, “I don’t even know them anymore! They’re afraid of me.” He feels terribly ashamed about his behavior and says he wants to do something about it, but he doesn’t know what to do. He is afraid that seeking help could endanger his license and practice.

Dr R is a 27-year-old, single diagnostic radiology resident in a large teaching hospital. She has a long history of trauma-related symptoms and episodes of depression for which she’s had intensive treatment as an adolescent and college student. However, once she entered medical school, she became convinced that continuing her mental health treatment would jeopardize her chances of acceptance into a good residency.

Now that she has begun her PGY2 she is experiencing increasing anxiety and sleep disturbance. She has difficulty falling asleep and frequent nightmares. Several months ago she began using red wine and OTC sleep aids in an effort to get sufficient sleep to function; she is often late to rounds and seems “spacy” and worried. Her residency director has referred her to a psychiatrist for assessment and treatment of what seems to be an anxiety disorder. At the first visit she is very anxious and admits to being easily humiliated and terrified that her “secret will come out,” by which she means that people will learn that she was sexually abused by her stepfather from ages 7 through 13.

Dr J is a 68-year-old general surgeon, divorced, with 2 daughters and 3 small grandchildren. He has recently cut back his practice hours to spend more time with his grandchildren. However, he is struggling in the health care setting because of his difficulty with the hospital’s new electronic health record (EHR) and having to type his operative notes into the computer rather than dictating them. There have been complaints by nursing staff and his colleagues that his notes make no sense, and he has outbursts of foul language at the nursing station while trying to find his patients’ lab results on the electronic system.

The hospital’s Chief of Staff threatens to suspend Dr J’s privileges if he does not undergo evaluation to find out why he cannot “get the hang of” the EHR. He comes to the neuropsychologist with the chief complaint, “Maybe I have Alzheimer disease.”

Assessment

In each of these cases there is some acute psychiatric pathology in addition to long-standing issues that have affected each physician’s ability to handle the stresses of medical practice, relationships, and adjustment to major changes. The first step in providing effective and meaningful treatment involves completing a thorough evaluation to identify all sources of distress, functional impairment, and potential danger to the physician and his patients. Given the resistance that most physicians show in accepting the patient role, such a comprehensive evaluation needs to include extensive interviews with the physician as well as collateral information from relevant parties, including referral source(s), family/significant others, current and past treatment providers, and in some cases employers or colleagues.

The goals of an initial evaluation of a physician are to:

• Arrive at a preliminary diagnostic impression

• Determine the severity of the condition(s)

• Assess whether the person is able to carry out his professional duties with reasonable skill and safety

• Assess whether the individual presents a danger to himself or to others

• Formulate recommendations for treatment

At this stage, the biggest difference between evaluating a physician and evaluating any new patient is the issue of the doctor’s safety-sensitive occupation. Questions about safety to practice must be explored during the evaluation because of the evaluator’s ethical responsibilities and, in most states, legal obligations. Depending on the specific state’s Physician Health Program, the evaluator may also want to consider whether enrollment in that program for ongoing monitoring and support would be appropriate and helpful for the physician.⁶

Caveats

Depending on the findings, the psychiatrist or other mental health professional who performs the initial evaluation may determine what continuing treatment is appropriate and acceptable to the physician-patient. Several caveats should be kept in mind when making treatment decisions.

Physician-patients present to a health care provider’s office with what may seem like a simple problem, illness, or symptom complex. But s/he is also dragging a heavy load of unresolved emotional distress

Individual office-based treatment of newly diagnosed moderate to severe substance use disorders in physicians is almost never successful and probably should not be attempted-even by providers who have expertise in substance use disorders. Such patients should be referred to the state’s Physician Health Program or to a specialized program with expertise in treating health care professionals for initial evaluation and treatment.

Many physician-patients will need ongoing psychotherapy and medication management after completing the initial intensive phase of care. When prescribing medication for a physician in medication-assisted treatment (buprenorphine, methadone, naltrexone) or for co-occurring psychiatric disorders, it is important to be certain that the physician is also receiving individual and/or group therapy and toxicology monitoring and is participating in mutual-help meetings.⁷

Most physicians who require treatment for depression, anxiety, and other stress-related problems present with a complex picture (see Case Vignettes) and will need multimodal approaches that can include individual psychotherapy, couples and/or family therapy, psychopharmacological interventions, and assistance in developing a support system. A psychiatrist or therapist who treats physician-patients needs to feel comfortable making the commitment to utilize all these modalities-or needs to assemble a treatment team that can address the patient’s various needs.

When the patient is a peer/colleague, it is tempting to join with the patient’s efforts to minimize the severity of symptoms by agreeing to less frequent visits, calling in medication refills, and not addressing cancelled appointments. It is critical to keep in mind that by the time a physician reaches out for help or is referred by an outside agency, he is deeply distressed and is in need of intensive treatment.⁸ For these reasons, it is generally inappropriate to attempt to provide psychiatric care and/or psychotherapy to a physician with whom one has a more complicated relationship, such as a personal friendship, supervisory or subsidiary role, business relationship, family connection, or other source of potential conflict.

Managing countertransference when working with physicians can be very challenging depending on the individual patient and the points of identification. The therapist may experience intense anger when the physician-patient fails to improve, relapses, or regresses in terms of professional or family responsibilities. Marked fear and worry about possible self-destructive behavior can interfere with the therapeutic alliance. Seeking clinical supervision is strongly recommended when working with these difficult cases.

Physicians may seek psychiatric care or therapy following an incident involving a boundary violation with a patient, colleague, or co-worker. These can vary from inappropriate prescribing for family, friends, or lovers to professional sexual misconduct, defined by most states as sexual or romantic contact with a person with whom the physician (or other medical professional) has a simultaneous doctor-patient relationship. The primary concern in such cases is that, consciously or unconsciously, the physician is exploiting the power differential inherent in the doctor-patient relationship, which can cause emotional harm to the patient.

Unfortunately, many physicians have had little or no education about professional boundaries. Most have heard that “it is not a good idea to date patients,” but may not realize that it is a violation of the Medical Practice Act and, in some states, a criminal act. An in-depth discussion of the legal, professional, and treatment aspects of professional boundary violations is beyond the scope of this article.

It is critical to keep in mind that by the time a physician reaches out for help or is referred by an outside agency, he is deeply distressed and is in need of intensive treatment

Most general adult psychiatrists and psychotherapists are not equipped to offer the level of expert evaluation and treatment planning needed in such cases. A physician who seeks assistance or is sent by a hospital or medical board should be referred to a specialist or specialized program experienced in conducting this type of evaluation, formulating a comprehensive plan of treatment, and providing the forensic reports and testimony that may be required.⁹

Some physicians are told to get help for their “disruptive behavior” in the medical workplace. This may include angry outbursts, harassment of hospital staff, use of vulgar or profane language, passive-aggressive refusal to complete medical records in a timely fashion or attend required meetings, and even violent acts such as throwing sharp instruments or punches in the operating suite. Some studies indicate that as health care delivery changes and physicians are under new levels of stress, this type of behavior is increasing in frequency.¹⁰

Physicians who are willing to accept help and to participate in treatment often do well in individual psychotherapy; some may also need pharmacotherapy for depression, anxiety, or other diagnoses. Participating in a “Distressed Physician” course can also be a helpful adjunct. Unfortunately, many physicians with “disruptive behavior” have entrenched narcissistic and obsessive-compulsive traits and are not willing to accept any responsibility for their actions. Their ability to benefit from psychotherapy is very limited.

Disclosures:

Dr. Ziegler is Medical Director at the Professionals Resource Network, Inc in Fernandina Beach, FL. She reports no conflicts of interest concerning the subject matter of this article.

References:

1. Gabbard GO. The role of compulsiveness in the normal physician. JAMA. 1985;254:2926-2929.

2. Leddy JJ, Moineau G, Puddester D, et al. Does an emotional intelligence test correlate with traditional measures used to determine medical school admission? Acad Med. 2011;86(suppl 10):S39-S41.

3. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy. JAMA. 2006;296:1071-1078.

4. Myers MF, Gabbard GO. The Physician as Patient: A Clinical Handbook for Mental Health Professionals. Washington, DC: American Psychiatric Publishing, Inc; 2008.

5. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015; 90:1600-1613.

6. Finlayson AJ, Dietrich MS, Neufeld R, et al. Restoring professionalism: the physician fitness-for-duty evaluation. Gen Hosp Psychiatry. 2013;35:659-663.

7. DuPont RL, McLellan AT, Carr G, et al. How are addicted physicians treated? A national survey of physician health programs. J Subst Abuse Treat. 2009; 37:1-7.

8. Gendel MH. Treatment adherence in physicians. Prim Psychiatry. 2005;12:48-54.

9. Brooks E, Gendel MH, Early SR, et al. Physician boundary violations in a physician’s health program: a 19-year review. J Am Acad Psychiatry Law. 2012; 40:59-66.

10. Rosenstein AH. Physician disruptive behavior: five-year progress report. World J Clin Cases. 2015; 3:930-934.