Becoming a Doctors’ Doctor

March 20, 2019

A teaching moment never to be forgotten, little did the author know that this action on his patient's part would be the harbinger of an amazing career looking after physicians.

PORTRAIT OF A PSYCHIATRIST

–Series Chair, H. Steven Moffic, MD

 

Dr Myers is Professor of Clinical Psychiatry at SUNY Downstate Medical Center in Brooklyn, NY.

I treated my first doctor-patient on Christmas Day 1970. I was in my second year of residency, on call in the emergency department, and a physician was brought in by the police from the airport. He had acted unruly and been argumentative with a flight attendant who refused to serve him more alcohol. His symptoms and behavioral changes all added up to mania.

When I presented him to my attending psychiatrist, who agreed with the “slam dunk” bipolar diagnosis, he asked me if I had certified him yet. I said, “No,” and he said, “Why not?” I hesitated. He asked, “What’s wrong?” I murmured something like, “But he’s a doctor.” The attending said, “So what-if he weren’t a physician, would you have certified him?” I immediately replied, “Of course, he’s really, really sick-and high risk.” He looked at me with a wise smile and said, “Go get the pink papers.”

A teaching moment never to be forgotten. Little did I know that this action on his part would be the harbinger of an amazing career looking after physicians.

Over the course of my residency, I also treated a physician with involutional melancholia (DSM II published in 1968), a doctor’s wife with a depressive neurosis, a medical student wrestling with homosexual urges (a form of paraphilia then, DSM II not yet updated to “sexual orientation disturbance”), and a doctor’s daughter with anorexia nervosa. Archaic nosology aside, I am grateful to these patients who taught me so much about what it’s like to be an ailing physician (or an ailing member of the medical family) and the impact of psychiatric illness on everyone in their orbit-their loved ones, medical colleagues, patients, and those who treat them.

By the time I finished my residency and opened up my half-time private practice, I was increasingly comfortable with having doctors and their family members as my patients. After 15 years as a generalist and facing more and more doctor referrals, I opted to restrict my work to physicians and their immediate family members only. And that is how I practiced for the final 20 years of my 35-year private practice, totaling more than 700 medical students and physicians.

The psychiatric concerns of physicians are far from monolithic. Here’s a snapshot of my work. All of my descriptions are disguised and composites of many to protect the confidentiality of my patients.

CASE VIGNETTE 1

Dr A was a 54-year-old department head in the midst of treatment for clinical depression. Safe to work but far from well, and living with altered concentration, she described her painful embarrassment when she noticed in the middle of a lecture to a class of medical students that her shoes didn’t match (students seated near the front of the amphitheater were staring at her feet). She also told me that she was relieved to be doing first call on her own without a resident-fearing that a trainee would notice her very slow assessment of new patients and her sighing.

CASE VIGNETTE 2

After several months of therapy with me, Dr B, a senior resident in a surgical subspecialty, ashamedly disclosed that she had been living with untreated bulimia since first-year medical school. Having been “caught” a couple of times buying bags of cookies and potato chips and containers of ice cream by medical colleagues at the 7-Eleven in her neighborhood, she was now driving blocks late at night to another convenience store to ensure the privacy of her illness.

CASE VIGNETTE 3

Dr C, a middle-aged internist, was living with bipolar illness. Recently separated from his wife, and psychologically derailed by this, he stopped his lithium. One week later, he crawled into bed in the middle of the night with his resident who was asleep in the on-call rooms at his teaching hospital. This astute and gracious young woman, albeit startled, had noticed that earlier in the evening while seeing a consult together Dr C seemed “revved up and kind of disorganized.” She got him out of her room, reached out to him, and he told her about his illness and that he was under my care. After she called me at home, I went to the hospital and managed to get him back on treatment and on brief medical leave with no further embarrassment to him.

CASE VIGNETTE 4

At the end of his first visit with me, Dr D, an intensivist, opened up his attaché case and passed me a stash of syringes, intravenous tubing, and ampoules of potassium chloride. “Would you please keep this for me? I don’t trust myself . . . I think I’m sicker than I look, Dr Myers.”

CASE VIGNETTE 5

Dr E, a devoutly religious married Christian physician and father of five, came to me because of guilt and shame associated with furtive anonymous sex with men. He began each visit with a ritual that, despite my discomfort, I respected. He got down on his knees, took my hands in his, and implored Jesus Christ to inspire me with wisdom to help him with his sin. It was acceptable to him that I was Jewish-and I liked that about him. Divine assistance and a hefty dose of clomipramine relieved this man of much of his anguish.

CASE VIGNETTE 6

Dr F and Dr G came to see me in the midst of a huge marital crisis. They were both in the same medical subspecialty and also the parents of two young children. Pregnant with their third child, Dr F had just been diagnosed with breast cancer. Dr G, with the closure of his hospital and downsizing of the department, had just lost his job. Reeling from this, he had started an affair with a medical student, Ms H, who was also pregnant by him. Dr F and Dr G did very well with treatment. And so did Ms H, who unbeknownst to them, was also a patient of mine.

CASE VIGNETTE 7

Over the phone, Dr I, a 31-year-old physician, said: “I’m not depressed-I’ve got dementia. Do you see physicians with dementia or should I call a neurologist?” He had no primary care physician-he had spoken to no one about his illness-his “dementia” was a self-diagnosis. I saw him that evening at the end of my booked appointments. He was psychotically depressed and required hospitalization and ECT.

CASE VIGNETTE 8

Dr J, a long-standing patient of mine, took his life several years ago. This man lived with terribly refractory depression to the chagrin of the psychopharmacology colleagues who helped me treat him. He also lived with enormous debt from not being able to work for long periods and being denied a disability insurance policy for preexisting psychiatric treatment. Because he had made two previous and near-lethal suicide attempts, I understood his death as the end of a long painful journey and that he was now at peace.

Asked by his parents to say a few words about him at his memorial service, I demurred. After discussing this with my therapist, I said “Yes.” What I didn’t anticipate was my degree of emotional upset. I really wasn’t able to string two words together, even with the aid of my written notes. Looking out at the tearful and ashen faces of his classmates and other medical colleagues, many of whom were or had been my students or patients, was very tough. My vulnerability and humanness, my need to grieve, had disarmed me. How I longed for the comfort and safety of my professorial or therapist cloak.1

My friends and colleagues often ask, “But what about you-what do you do to stay well?” I’ve never felt that my work is any more stressful than any other psychiatrist’s, with perhaps one exception. When we treat other physicians and their loved ones, we are often gazing into a mirror-and that is painful when you are not feeling very well or there is unrest and unhappiness at home.2,3 I’ve had to fight for balance so that I don’t shortchange my family or neglect my own need for self-care. Keeping good boundaries is also a challenge when treating physicians, but it is doable and essential for state-of-the-art care.4 I’ve never been reticent to get second opinions when I’ve been stumped or faltering; not only can my physician-patient benefit, but I do too. Most important, I’m blessed with physician-health colleagues near and far whom I trust and respect highly. They have helped me with countertransference dynamics that have stalled or muddled treatment-and I’ve been able to regain momentum and focus.

Being a doctors’ doctor has been an enormous privilege and honor. Bearing witness to the relentless and pernicious stigma in the house of medicine and how that ravages the minds and souls of our brothers and sisters in medicine has been a driving force. But I am not discouraged. Through my teaching and mentorship, I know that there are many young and early-career psychiatrists taking up the reins and making a commitment to physician health. And they love to hear my Christmas 1970 story!

Disclosures:

Dr Myers reports that he is a member of the Medical Education Speakers Network and received honoraria for grand rounds twice in 2017; he also receives book royalties from American Psychiatric Association Publishing Inc., Amazon CreateSpace, Sage Publications, and Gotham/Penguin Books.

References:

1. Myers MF. Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared. New York: Michael F. Myers; 2017.

2. Myers MF. Cracks in the mirror: when a psychiatrist treats physicians and their families. In: Sussman MB, ed. A Perilous Calling: The Hazards of Psychotherapy Practice. New York: John Wiley & Sons; 1995:163-174.

3. Myers MF. When physicians become our patients. Psychiatric Times. 2000;17:45-46.

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