A physician I worked with booked her first appointment with me at 6:40 in the morning, before rounds, from her car. Not because that was the only slot available, and certainly not because I prefer meeting that early. It was because that was the only hour of her day that nobody else had a claim on, and she didn’t want anyone at her hospital to see it on her calendar.
She had been thinking about reaching out for therapy for four years.
I specialize in working with physicians in therapy, and that years-long delay is the most consistent thing I see. By the time a doctor sits down across from me, they have usually already tried the entire menu. The wellness webinar. The meditation app with the streak counter. The resilience module their institution assigned them, which several of my clients have described, accurately, as being handed a pamphlet about drowning while still in the water. Some have tried therapy once before and left after three sessions because the therapist wanted to teach them box breathing.
So they arrive skeptical, which I think is reasonable. And they arrive with a particular apology already locked and loaded: I know I don’t have it as bad as some people. A trauma surgeon said that to me twenty minutes into a first session. He was working eighty hours a week and hadn’t been to his own doctor in six years.
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Here is what I have come to understand about that opening line. It is not humility. It is a chronic habit of minimization when it comes to personal struggle. Physicians are trained to triage, and a person trained to triage will always find someone sicker, which means they will always be able to justify not being the patient. It is an elegant system for never getting the care and support they need and deserve.
Here’s my take on where the actual material turns out to be. The “presenting problem” is almost always the job itself. The hours, the charting, the administrator who has never touched a patient, the moral injury of practicing inside a broken medical system where patients are more and more apt to treat their clinical judgment as a suggestion. All of that is real, and I never argue with it. The workload is genuinely unsustainable, and no amount of therapy fixes a broken model.
But when we get past the first month or two, the material underneath tends to be older than just the job. Three patterns usually come up again and again.
The first is achievement used as a means to emotionally regulate. Doing and accomplishing is not just a conduit for ambition, but it has become a coping strategy. For a lot of the physicians I work with, performing well is the only reliable way they have ever found to feel okay, often going back to childhood. Which means rest doesn’t get experienced as just rest. Instead, it reads as exposure and vulnerability. This is why the vacation advice falls so flat. You cannot send someone to Hawaii to recover from a problem that gets more apparent when they are forced to stop moving.
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The second is self-erasure that got professionally rewarded. Medical training takes a person who was probably already good at overriding their own needs and hands them a decade of formal practice in it, with praise and reinforcement attached. You do not eat, you do not sleep, you do not grieve the patient you lost on Tuesday because there are patients that still need to be seen on Wednesday. That is not a character flaw. It’s adaptive, and it has worked, and nobody ever told them there would be a point where it stopped working.
The third is the belief that needing help is a competence problem. This one is the most consequential, because it is what produced the four-year delay. The people I see are the ones other people call when things go badly. They are the fixers. Being on the other side of that arrangement where they’re now in the client position, it can feel less like relief, and more like a role reversal they have no script for.
The difficult thing I often tell my physician therapy clients is this: quick fixes are never really going to hold for long, unless the deeper stuff is aired out. If a breathing exercise were sufficient for this, these are the last people who would still be suffering. They are disciplined, they follow protocols, and they are excellent at homework. If a worksheet could fix it, they would have fixed it themselves years ago, probably while also training for a half marathon.
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What tends to actually help is slower and less satisfying to describe. Depth-oriented therapy, where we go after the thing driving the patterns, instead of just managing their output. I am also frank with people about the timeline. I am not going to promise a physician that in six to eight sessions, they’ll have a new life, because they will know I am lying, and I will have lost them.
One more thing worth saying to this audience specifically, since many of you are the colleague in whom someone eventually confides. The single most useful thing I have seen a peer do is stop asking whether someone is okay. Everyone says a reflexive yes to that. Instead, what works better is actually saying what you have noticed, plainly, and then saying that you know someone good who could help. Specificity gives permission in a way that vague expressions of concern don’t.
That physician who called me from her car eventually moved her sessions to the middle of the afternoon (thank goodness for me, selfishly). She blocked and protected the time on her shared calendar, visible, no explanation given. She told me that was harder than anything we discussed in the room.
Quick fixes are never really going to hold for long, unless the deeper stuff is aired out. If a breathing exercise were sufficient for this, these are the last people who would still be suffering.
