Podcast: Psychiatry tips for physician wellness: preventing and treating burnout and addiction
About 42% of physicians report feeling burned out, and about half of all doctors are making active plans to leave the practice of medicine. Unfortunately, some doctors turn to drugs and alcohol to cope with the stressors of medicine, which may result in the loss of their professional licenses. Today, we are talking with Dr. Daniel Hochman, a psychiatrist, and an online professional recovery program creator to discuss physician well-being.
Dr. Daniel Hochman's online recovery program: https://www.selfrecovery.org/about-dr-hochman/
Physician support line: 1 (888) 409-0141 https://www.physiciansupportline.com/
"Psychiatrists helping our US physician colleagues and medical students navigate the many intersections of our personal and professional lives" - free and confidential
Daniel Hochman MD 0:07
Welcome to "Patients at Risk," a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host, Dr. Rebekah Bernard and I'm joined by my co-host and the co-author of our book, "Patients at risk: the rise of the nurse practitioner and physician assistant in healthcare." Dr. Niran Al-Agba.
Niran Al-Agba MD 0:25
Rebekah Bernard MD MD 0:26
About 42% of physicians report feeling burned out, and half of all doctors are making active plans to leave the practice of medicine. Unfortunately, some doctors turn to drugs and alcohol to cope with the stressors of medicine, which may result in the loss of their professional licenses. Today we are talking with Dr. Daniel Hochman, a psychiatrist and the creator of an online professional recovery program to discuss physician well-being. Dr. Hochman, welcome to the podcast.
Daniel Hochman MD 0:54
Thanks a lot for having me, Rebekah.
Rebekah Bernard MD 0:56
Daniel, can you start us out by talking about your background as a psychiatrist, and what drew you towards the treatment of addiction and substance abuse?
Daniel Hochman MD 1:04
I had gone into medicine sure I was gonna be an ER doc. So that was kind of the best fit for my personality at the time. But I'm a very sort of deep and analytical thinker and got frustrated wanting to figure out why people were doing what they were doing. And so the story went on that way, and I became a psychiatrist. I fell into a lot of work with addiction. I don't necessarily have the same story that I'd say most do outside or inside medicine, that end up treating addiction. I don't have like a deep dark past of, you know, my own long battle personally. Like a lot of people, I have plenty of friends and a couple of close family members where it's affected a lot of things and so a lot of experience right around it. But yeah, that had some influence on guiding me towards it. But I find addiction really captures a lot of what we get so confused about around like, 'Why do people behave certain ways and do what we do,' which is kind of at the heart of my practice. So you know, like, if you're depressed, well, why don't you do things that make you happy, then? or, Why can't you just forget about things that bother you? Or, why can't you address your fears? You know, it's very strange when you start to think more about it. And addiction captures a lot of that. So it's something that fascinates me. And then I've had the joy of working with people and find that it's one of the most medical and scientific areas, it's, it's just like, beyond the, it's very siloed, outside of medicine, as we know. So that has drawn me to because it's been very helpful for people around me to help bring some science to the field.
Rebekah Bernard MD 2:48
Now, Daniel, do you specialize in the treatment of physicians? Or is that also a part of your practice?
Daniel Hochman MD 2:53
I do see a lot of physicians, but it's not something that that I tried to make a large part of my practice or anything. I see all kinds of people.
Rebekah Bernard MD 3:01
What can you tell us about some of the special needs that you see in physicians? I've read the statistics, and what I've seen is that doctors are pretty much right on average, with the general population for issues with substance abuse. It's about 10 to 15% of physicians have trouble with drugs and alcohol, but is there anything particular to physician practice that might make us more susceptible to addiction issues?
Daniel Hochman MD 3:26
Yeah, the thing that makes us most prone, really, is that we're very high achievers. So, you know, you have certain traits and characteristics. Of course, just being kind of Type A - if we are using laypersons sort of words and definitions here - we are very prone in that way. And, you know, I think maybe what you saw there is generous to physicians, we often have very high rates of addiction and substance use. So, in general, as a whole class, physicians were at much higher risk of opiate abuse. Alcoholism tends to be more specific to the specialty and things like that. So, the highest rate of any addiction of any field in medicine are female surgeons. Female surgeons are the highest risk, anesthesiologists are higher; so a lot of the specialties tend to be higher. Family Medicine tends to be lower. So it depends on the specialty. But if you follow some of those things out, they do point towards the association not, of course, being because anesthesia or surgery necessarily, you know, yes, surgery can be very high stress, but in the research that I've done around this, and this includes researching around executives, different kinds of high-stress environments, it's not necessarily the stressful environment that is causing addiction. That's that people tend to seek out high-stress fields when they have a lot of the precursors that are the setup for addiction.
Niran Al-Agba MD 4:59
What are the precursors?
Daniel Hochman MD 5:02
In a nutshell, an upbringing that is focused on results and achievements. It might also include a lot of criticism, things like that. It could be outright abuse and trauma. So, you know, I do see physicians that have had terrible childhoods, and the public, I think, thinks that we had, you know, all these, like, amazing privileged upbringings. And, we know we study alongside people, and that's just not the case. Yeah, you've got your occasional just run of the mill, great childhood, great grades, great, you know, life story, and it all worked out well. But, we know that that we're just regular people; a lot of us have gone through traumas, abuse, losses, you know, real hardships. And so a lot of those things coalesce. Then the simplest way to put it is, you know when life is not fun growing up, that's the simplest way to say - that's a precursor. More specifically, a few of the things that develop into the traits of addiction, tend to be more around - really focused on those results and things. So parents or an upbringing, just the culture around you, when it's more focused on grades than learning the actual subject, or focused on prestige and what schools you are getting into - stuff like that. You can imagine then, that it might be that someone who becomes a doctor is focused on going to good schools and stuff. But what came before that was that to them, grades were like everything, instead of just finding science or bodies, or the cells, you know, fascinating. So people who grow up and you know, go on to be doctors that are just like, fascinated by biology from the beginning - they have a really good, natural, healthy relationship to the body and health and being a doctor. But for a lot of doctors, that's not really how they came to it. Yes, of course, the body is very interesting. I mean, I think everybody is interested in science and the body. So it's not that like a high achiever, you know, high-pressure kind of doctor isn't interested in the bodies, you can't let that confuse you. It's more that well, how did you naturally come to it. And then if it was, well, I wanted a high-paying job, I want to raise a family, I want to be able to retire early, I want to, you know, have a prestigious job. I want to have a good reputation as like a good professional, all those kinds of things. They're fine, right? Those aren't terrible motivations. That's, I think, what drives most people to do what they wind up doing. But that's a different relationship to work, then I'm just totally fascinated with the body and I had to become a doctor. So a lot of that criticism, a lot of focus on outcomes, which could be grades, and then trauma. And then there are other subtle things as well, that that can kind of coalesce into that. But a high-pressure, not very fun upbringing is the short answer.
Niran Al-Agba MD 7:54
So what I hear you saying is people who sort of drift to medicine, yeah, you know, because they love it. They just, they're fascinated, they love it, they think it's gonna be amazing. Versus we're raising a doctor, we're raising a this or that. And I think that's what I hear you saying, which is interesting because I've always said, fun has no place in childhood. So I may have to revise it. But I guess I wanted to separate out because as the pediatrician, you know, I spent a lot of time telling families that not every kid needs a trophy, right? They need positive reinforcement. I'm so glad you tried hard. I'm so glad you worked. I know it's disappointing. I love you anyway. That kind of stuff. But not the, you're my little genius, and you can do anything you want. Make it fun, right? I just want to separate those two if we can.
Daniel Hochman MD 8:41
You're absolutely right. Yeah. So it is a fine line. So you know, I was talking about the one end where it's really not fun, and not just not fun, but bad. You know? You're scared. They're scared that they're not gonna wear the right thing. They're scared to come home. And they're gonna ask how I did my math test and or just even subtle things like, Well, you know, how are you getting along with all your friends? And you're almost afraid to say not well, because then they're gonna call the other parents or call the teacher and you know, just so interventional, and just like trying to make that kid be the best. So, you don't want them growing up scared of those things. But also, yes, exactly what you're saying and that the whole trophy kind of culture we have is equally awful. It's just a very - it's another bad thing. It's on the other end of it. And what that takes away psychologically, is called self-efficacy. When we don't feel like say you're on the softball team and get the trophy at the end. And you're like, Well, everyone got a trophy. And that sounds nice. But we know and research is really clear - that child does not develop self-efficacy, meaning that they don't get to learn, Oh, wait, when I put work in, and when I really pursue something and see it through that, that does something. Instead, it's just this cheapened result. And so like everyone's the same, it's like, no, everyone's not the same, you know, and some people are better at other things. And so we want to know, like when we really try hard at something, that that can amount to some kind of achievement, right? So we don't want to be pressured to achieve, we want to be fostered to achieve.
Rebekah Bernard MD 10:20
Well, it's so interesting that you say that because right when you when you're mentioning that I start thinking about how doctors are feeling nowadays, that with this whole trophy mentality, you know, it's as you know, extremely tough to get into medical school. It's very competitive, you work really hard, you finally graduate, you go through your residency, you do all of these things. And you're rightfully proud because you've accomplished a lot. And then you've got other people coming in, that went to an online school that had a 100% acceptance rate, and you're told, well, they're just as good as you are. And I think it is maybe part of this whole trophy mentality that everybody's the same, and we're all just as good. And we're all on a big team. And you have to wonder how that affects morale in a physician as they're experiencing this, especially the young ones.
Eric Hochman MD 11:05
Absolutely. You know, I like to point that out. It's a grownup version of this. We're all lining up, and you know, playing, and we went through serious training camp, and then you're done. And then the other person went through something much quicker. And let's say it gets, you know, 90% of the reimbursement. So you're let's say you get a nine out of, you know, a 9/10 as big trophy or something. So it's pretty indiscernible, right? It's pretty much the same trophy. So you're sitting there like, man, I went through training camp, I did the spring training, I did the summer camp, like all about the baseball, and everything, right? And then the other one just gets to show up and you know, and gets the same thing. And it's about self-efficacy - you can paint it pretty or ugly. You can cast it either as well. It's this beautiful thing. There's room for everyone. You know, we've got more patients to see, why are we trying to be competitive? This isn't baseball, this isn't, you know, just everyone can get this privilege of treating patients. But of course, there's the dirty side, which is, you know, well, there are patient's lives at risk. And that's deceiving as well.
Niran Al-Agba MD 12:20
I think that's something that they want to they that, especially like the American Academy of Nurse Practitioners, which I find fascinating. You're describing that mentality. And I'm sure there are physicians who have this mentality to where it's a competition. Yeah. Or it's like you said, like, they're taking a piece of the pie. And it's so interesting because I know Dr. Bernard and I have been labeled that way, obviously, following the book. But it's interesting to hear you talk about this because I loved biology from the time I was five. And I knew I wanted to be a doctor. And I imagined everything I imagined I'm doing now every single day, right? Like, it is such an honor, it is such a privilege. I'm seeing third and fourth-generation patients because my dad was obviously in the practice before me. So like you said, I never gonna be replaced. Like there's no doubt other than me keeling over dead, there's not really going to be any way to stop me from doing this to a certain extent. So I agree with what you're saying about being so fulfilled because it is what I love, I really, I used to say, I like that I can pay for my house. But I would honestly do it for free because I just love it so much. And I still do after 20 years. So I think that's a definite personality. And like a group. It's interesting, I think I'm finding that the people like you're describing that were, they're going to be the doctor in the family, or they had this idea that being a doctor was this special, amazing, high powered prestigious thing, which, unfortunately, it's really not anymore. So I guess what I want to know is how either how responsive are those people to treatment, I imagine it's got to be hard to get to this moment, after all this hard work and be like, Okay, everybody gets a trophy. And I'm nothing special because I'm just a doctor. And so how responsive are those kinds of patients to treatment, just as a general rule?
Daniel Hochman MD 14:01
It kind of depends on how they come to treatment. If someone comes to the treatment, and they already understand what you just said, then that treatment can go really well. Essentially, that's a grief process, right? You're grieving like this is not what I thought it would be. And just to tie it into what we were saying if you were going into medicine because of the sort of lifestyle or the prestige of medicine, and remember, we're not counting that as a bad thing. It's a very good thing - it's a noble profession, and you're wanting to be an esteemed person and society will then realize you got here and it's not probably what you think. And so if you went into it with the relationship to the job being the job itself, rather than like you're saying your relationship to it as well, yeah, it's a job or whatever. But, um, can I see the patient, please? That's a different relationship to your work. So the people who relate to it as just the profession, as long as they're understanding what they're struggling with, and they enter treatment with that, it does amazingly. The problem is I see a lot of people struggle, and only understand the part where they're burnt out, like, that's the part that's really easy to see you're working, you're burnt out. But that's sort of like, to me a symptom, you know, you can get burnt out for all kinds of reasons. So it's like, we know, you can get a fever for all kinds of reasons, you can get burnt out because of home life, or because of other you know, other things going on, burnt out, because you're seeing too many patients or too little pay or too little time off or whatever. Like there's, there's a lot of reasons you can get burned out. All the charting and that may not be a reflection of something going on, truly, you know, underlying all of this stuff that's burning you out. So, that's what I see gotten missed, you know, as far as like, what you're kind of asking is, the treatments don't necessarily go well, when they present, I'm burnt out, I need a therapist to talk this through with, and then you're just kind of sitting there figuring out, well, how can we create more time? Or have you told them, you know, that you need more time with patients or something? Typically, we're really smart, right? You know, doctors can usually work through those things and kind of figure that out, does it help to sometimes have a little encouragement and accountability? You know, just taking a stand for ourselves? Sure. You know, that's not like wasted time. But that's not therapy, you know, that's just kind of coaching. And I differentiate between those.
Rebekah Bernard MD 16:30
Can you differentiate a little more? Because I've got to tell you that Niran and I talk about this all the time, we see all these physician coaches popping up all over the place. And a lot of times, they're not psychiatrists, they're family doctors, there's an ER doctor, all sorts of people. And I almost always see them quitting clinical practice to become a physician coach. And I'm like, so you're gonna tell me how to be a better doctor, but yet, you don't want to be a doctor anymore? Like I kind of see it as like, they're looking for a way out of clinical practice. And I know many of them, that's not why they do it. But I can't help but think that I happen to be a big fan of psychiatry and psychology, for really trying to figure out the root of issues and in coaching is good to, you know, just to be very goal-oriented. But sometimes you need someone to help you get that to that epiphany, where you realize, wow, I'm a doctor, maybe for the wrong reasons. And maybe I need to change the way I think about things. And that's more than just coaching that requires a to me a psychiatrist or a really good psychologist, can you share your thoughts on the differences?
Daniel Hochman MD 17:29
Yeah, I'll first say a very talented, experienced, naturally gifted coach might be doing the same kinds of things, and an amazing therapist is doing so that said, for the most part, yeah, I mean, a coach is going to have the kinds of training that a coach would have, right that it's a lot of books and seminars, and retreats, and whatever. We can appreciate talking about the difference between doctors and other providers, we can appreciate the difference, right? So, you know, I think I'm speaking to an audience that immediately understands the training for a psychiatrist is on a very different level than for a coach. And so a coach would be very good if you're trying to navigate things that rest on logic, or logic, you know, so it's, I shouldn't say, logic, the logic side. So what am I going to try and change about the practice? What am I going to try and change about the partnership, or the ownership or the contract, or my home life and I'm going to try and work out more all my Saturdays are out, bla, bla, bla, coaches are very good at helping set boundaries and helping to kind of give permission or accountability to things that make sense. And that's when there's logic. A psychiatrist, or a very good psychologist, they're gonna be more attentive to process-based things. And the parts that don't necessarily make sense. So why do I keep doing this when I know that it's bad for me? Now, that's a psychiatric kind of question. Or, I know I need to do that. But I can't leave when I know that my patients still need help. Well, yeah, you're a helper, we have to look at why can't you know you need to set boundaries, you know, you need to leave work and get home to your family. Why aren't you doing that? That's a psychiatric question. And it might not be even that it's like a full-on major depression or, you know, anxiety. It's just that requires a little more depth of work that's going to really look at things about your childhood, things about, you know, these processes that were programmed very early on, and your relationship to people to things to like we were saying with work. Why do you need to help people? Is it, what's the idea there? What are you running from? Those are more in the space of true therapy.
Niran Al-Agba MD 19:59
I'm glad you brought up boundaries because I think it's such an important topic for probably physicians and almost anybody who works in health care, I find, and again, this is just my limited experience that a lot of the physicians who either get in trouble or have problems or end up with substance abuse, generally, and again, this is my limited experience, but generally there is this boundary problem. And it's not always the same kind of problem. So can you comment on that at all, and how a psychiatrist helps people with their boundaries?
Daniel Hochman MD 20:30
Yeah, boundaries in the way you're talking about are usually going to be because you're pushing too hard. So and there's a different type, we could maybe name just a few kinds of...
Niran Al-Agba MD 20:40
Well, patients pushing too hard. What I find sometimes is patients, either physicians will cross this line, or patients will and now we're even finding, you know, nurse practitioners, PAs, everyone can be guilty of forming a too close of a relationship or getting involved sexually, or whatever it is, crossing those boundaries of what I would call a doctor-patient or something along those lines.
Daniel Hochman MD 21:00
Okay, so if we're narrowing into that kind of breach, and now you know, you're intimate, or, or just making advances or something with a patient, I don't just view that as, Oh, wow, there's this instant chemistry. I mean, maybe there is I mean, we're, we're humans, so there can be chemistry, but we're also humans, and, you know, not primitive animals. And so we usually want to see past, you know, just some instinctual idea. So, so yeah, you know, I view that as a thing to tend to not just, oh, wow, that's a nice romantic connection, whether married or not, I would still treat it - I mean, that there are different scenarios, of course - but I would still treat that as a real issue. And there's a lot of paths that can lead to that one of the most common for a doctor to do that would be that it might be revealing that that doctor is very driven to be well received and well-liked. And so in a, in a weird way, then, Yes, it's taking advantage of a prestigious position. So there is that dynamic, you're really an authority, and you're someone that person is looking up to. And so you have answers, you're the person that might be filling in what that person's always been seeking, right. So it's usually not just one way, usually, they can kind of smell when that patient is all too susceptible, very smitten with someone with power, who is you know, willing to give them attention to and so it's a when someone can give in very easily to that, that would be revealing of something you'd want to discover, you know why you needed that for me, you know, I don't make people feel stupid or punish people for that. Instead, you want to help them in a way that doesn't involve shame, try to discover why did I need that kind of attention? Why did I need to confirm that I could get that person? There are usually holes in that person's psyche that their, their gaps growing up, you know, where they weren't getting something,
Rebekah Bernard MD 22:58
I think you touch on such an important point, which is that we are human, we are not superhuman, and we kind of have this idea as physicians a lot of times that we have to be perfect. And if we're not perfect, then we're no good at all, I have the belief that every physician pretty much should have a psychiatrist or a psychologist because most of us have these issues. And it's not easy to take care of patients. And I've learned so much from working with both psychologists and psychiatrists, all these tips that have helped me to understand myself better and to help my patients better. But there's a big stigma, as you know, and especially for physicians, many fear licensing issues. So what suggestions do you have for doctors so that they can get help, ideally, before they get into trouble? But of course, if they're getting into any trouble, they need to get it right away.
Daniel Hochman MD 23:44
Yeah, you know, we work so hard to get our degrees and keep our licensure always for doctors - you know, just get on it. You know, don't wait. If it's like the boundary issues you're talking about. If it's substances and drinking, of course, then that's riskier. Please go even faster in to try and figure that out. If it's softer things, that's when people usually do take too long or never go get help. But whether you do have something that that you're really worried is going to become, you know, a licensing issue, the board review or not, right, and it's just that you're getting burned out, and life is just getting increasingly hard. Remember, physicians have huge rates of suicide. So we want to get ahead of that. That's what I hope for anyone in our field, it's a tough job, especially now with all the charting and then we're getting squeezed from every direction. So whether you have a troubled childhood or you were doing fine and now just getting squeezed in corporate medicine just get in sooner than later. And, you know, I liken good therapy to like physical therapy. I entered physical therapy because I had a bad hip. At this point now I'm just enjoying always figuring out new things to do for my body that have nothing to do with my hip. And so that's what I hope for people is you don't just wait and go in for the hip. Don't wait and go in for depression or someone caught you driving drunk, go in just because you want to make life better. And that's, that then is bringing some joy to it is so much more fun to sit down in therapy and figure out like, my mom did this, my dad did this, and why am I different than my brother? And why? Oh, gosh, I'm doing that with my kids. And why aren't I doing anything I like anymore? Like, it's fun to figure that stuff out.
Rebekah Bernard MD 25:34
Yeah, when you have those epiphany moments, like you're like, ohhhh, and then you can actually make changes in your life. And it's something you just never saw before. But with someone that can help you see these things, because they're insightful, and they were trained, as psychiatrists are trained, very specially to be able to do that. Now, what about doctors that are worried about - will it come back to haunt them? If they see a psychiatrist? Would you think that we would just be able to say, Well, no, I'm just going - I'm not, I don't have a psychiatric diagnosis. I'm just going because I want some tools. And I want to learn how to be the best doctor I can be.
Daniel Hochman MD 26:10
Yeah, if you want to be really safe, what shouldn't ever really be a legal concern, or, you know, opening yourself up to some kind of liability there is to seek treatment out of pocket. So you know, not going through insurance. Once it's through insurance, it's recorded, right. And we all know that maybe maybe not ever really safe from anybody else being able to discover. So if you can go in sooner, get treatment that is out of pocket, and that doesn't require that any diagnostic codes or anything like that, then it's off the radar, so to speak. And it also allows you then, if you're ever questioned, you know, on renewal or a board review, or anything, like did you ever need treatment for something that was impairing your practice? You can say no, if it's because you were trying to figure yourself out, that might be hard to answer. And you could get nailed one day if it's because you were driving drunk, and were court ordered for it or something. So going in sooner - keeping it fun. And if you've got the finances to do it, you know, out of pocket, so it's not getting run through insurance. That safe, right? I mean, you and then you can honestly answer that question that you were never getting treated for anything that where you were impaired in your pack.
Rebekah Bernard MD 27:26
And I mean, to be honest, psychiatry and psychology are not phenomenally expensive. I mean, yes, you can find very expensive people, but you can find very reasonably priced cash prices. Also a lot of medical societies like mine, we have free - that's paid for, for our members - psychology sessions. There is a free confidential psychiatry physician support line, which we'll put up in the in the notes. And Daniel, one of the things you've done is you've actually created an online recovery program, is that something that physicians could be used that they wouldn't have to worry about being discovered?
Daniel Hochman MD 27:59
Yeah, a lot of physicians have found that very useful for that reason, what the program does is walk you through all the things that you'd want to do to do the real depth of the work to deal with it. It's not just superficial around, you know, don't drink or don't do drugs. It's, it's gonna help people, you know, discover a lot and the physicians really like that because they get to go through that deep work without it's a, you know, technically it's a course or product, right? It's not it is absolutely not a medical treatment. And I like that it's not I'm not trying to call it treatment or reach that stature. It's just something someone can go find and do and so that Yeah, they're not liable at all for that, that exposes them there. There's, there's no trail or connection to their medical care with it. And, and I like it that way.
Rebekah Bernard MD 28:50
We'll definitely include that link in the show notes. Daniel, it's been so great talking with you. Thank you so much for joining us. If you'd like to learn more about this topic, we encourage you to get our book. It's called "Patients at risk the rise of the nurse practitioner and physician assistant in healthcare." It's available at amazon.com and at Barnes and Noble, we encourage you to subscribe to our podcast and our YouTube channel. It's called patients at risk. And if you're a physician, we'd love for you to join us at physicians for patient protection.org Thank you so much, and we'll see you on the next podcast.
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