Is the Sick Voice of Medicine Making Doctors Ill?
How medical culture interacts with personality traits to bring out anorexia.
Posted Aug 02, 2020
Medicine attracts people with the types of personalities that put them at risk for developing eating disorders. Temperamental traits such as perfectionism, self-discipline, dedication, self-sacrifice, fear of making mistakes, altruism, and a tendency to please others are highly valued in medicine. Although these traits may contribute to external success when channeled appropriately, they have the potential to become destructive if turned inward. Exposure to the stressful, rigorous, and competitive environment of medical training provides the perfect conditions for an eating disorder to manifest.
“Doctors tend to be somewhat perfectionistic, anxious, rigid and have worked very hard through their lives succeeding because of these traits. When people like this come into contact with a highly demanding field in which there may not be as much empathy for what a person is going through personally, and where there is not a lot of time to recharge, an eating disorder can certainly be brought out.” —Jennifer Gaudiani, M.D.
I know these aspects of my personality have been instrumental to my success in medicine. But, as I relapsed repeatedly into anorexia, I was forced to acknowledge they were also instrumental in keeping me ill.
One reason I have found recovery so difficult is that letting go of anorexia appeared to necessitate eliminating the aspects of my personality that perpetuated my illness whilst simultaneously retaining those that make me a good doctor. I spent years going around in circles asking myself if recovery was compatible with a career in medicine. Part of me believed I needed to hold onto illness to continue to achieve the things I thought I needed to achieve to be a successful doctor. Or that I would need to leave medicine completely in order to recover.
Whilst researching this post, I was fortunate to speak to Jennifer Gaudiani, M.D., eating disorder expert physician and author of Sick Enough: A Guide to the Medical Complications of Eating Disorders, whose wisdom and insight helped me finally put what I was slowly coming to realise myself into words.
Doctors are often highly sensitive, other-regarding, external validation aware, and rely on points of authority to feel they have done something properly rather than an internal sense of knowing we are enough.
“We select people who are highly organised, diligent, competitive, and perfectionistic, who are willing to sacrifice personal wellbeing or peace for an outcome,” says Gaudiani. “We take these individuals who are highly other-regarding, really hardworking and self-denying, and put them into a highly patriarchal and hierarchical system. … so, who could be surprised when all of those traits that are praised and are markers of success and progress tip over and eating disorders develop.”
Doctors are trained in an environment that contains abundant triggers for developing eating disorders. People who strive to reach impossibly high self-imposed standards are placed in a highly pressured setting, combining stress, competition, and erratic schedules for eating and sleeping. We are expected to demonstrate physical and emotional endurance, to work long hours without breaks, and to set aside our emotions to become desensitized to illness, death, and suffering. Being "too busy to eat" has been the norm in many of my hospital rotations, with lunch an indulgent luxury or unnecessary interruption to continuous provision of patient care. I have heard senior clinicians admonish their juniors for being “weak” for asking to grab a sandwich at 3 p.m. In this type of culture, nobody wants to break first—particularly not a junior doctor who wants to make a good impression.
“Where did it become ok to work through meals?” asks Gaudiani. “Where did we decide that fixing others’ illness requires us not to take a breath to process the grief of seeing someone die and understand it affects us? We need to speak about how it makes us feel sad. And how it reminds us of the loss of our own mother, or grandmother, or child. We are all human. And part of human fellowship is sitting and eating together, laughing and sharing stories about our own narrative so we’re not showing up as blind robots.”
Doctors cannot deliver high-quality care if we neglect our own basic physical and emotional needs. It goes back to the analogy of putting on our own oxygen masks first—of course, looking after patients is paramount, but nobody can perform optimally when hungry, thirsty, and hypoglycaemic. And nobody can demonstrate compassion when traumatised and grieving themselves.
In contrast to the assumption that relentless hunger-fueled work increases productivity, evidence suggests eating disorders impair clinical performance. People with anorexia do poorly across a range of neuropsychological tests, showing reduced concentration and decision-making skills at a low weight (Cavedini, 2004; Tchanturia, 2005). A doctor who can’t concentrate, think clearly, or make effective decisions—either because of an eating disorder or simply because they haven’t taken time to eat—could potentially put patients at risk.
We need to look after ourselves and our colleagues. Being nourished, hydrated, connected, and acknowledging our humanity will not only make us more productive, it will make us better doctors. We need to stop dabbling in archaic values—feel nothing, keep on working, don’t stop—and see this for what it truly is. Any idiot can work themselves to death. It’s not a sign of strength—it’s succumbing to a toxic and outdated system and being too blind or weak to fight against it. We must reframe refusal to participate as an act of proactive rebellion and, in doing so, we can start to heal the part of us that tends towards an eating disorder.
“The focus must shift from asking how we can simultaneously do medicine as medicine asks us to be, and be recovered, healthy, values-honouring people. We must change the question and ask instead, why is medicine asking us to show up this way? What is fundamentally helpful to the ill individuals we have the privilege of caring for about becoming self-denying automatons who can never give ourselves a break?” —Jennifer Gaudiani, M.D.
In the years I have spent asking myself whether it's possible to eliminate the personality traits that contributed to anorexia and still be a good doctor, I have been asking the wrong question. Perfectionism, self-discipline, self-sacrifice, and my tendency to put work above pleasure don’t make me a good doctor. Just as being thin doesn't make me a good doctor. Yes, these things have helped me to succeed in a toxic culture and be accepted in a fat-phobic, diet-obsessed society. But that is not the same thing. The traits that make me a good doctor are my compassion, my humanity, my kindness—these are my true values. And they are absolutely compatible with recovery.
The sick voice of medical training culture reflects the sick voice of the eating disorder. If we recognise this and challenge both, we can simultaneously build a healthy work environment whilst restoring our own health and well-being—and that of those around us.
“Our perfectionist ears will hear the sick edicts of medicine and amplify them. Those who can resist will hear those sick edicts and say look, I’m going to do a good job and f@£k the rest of that. But to everyone else it will be very egosyntonic. The sick voice of medical training will reflect the sick voice of the eating disorder and feel very familiar..and so they can’t help but fall into it.” —Jennifer Gaudiani, M.D.
Just as we challenge the voice of our eating disorder—the constant barrage of thoughts telling us that however much we give beyond our boundaries we will never measure up, that we must eat less, move more, work harder, deny ourselves pleasure, be perfect—we need to resist the sick voice of medicine. They resonate with and amplify each other, we lose ourselves in the noise, we become overwhelmed, we spiral, and we cannot see it.
We’re telling ourselves we’re not enough in a culture that seems to confirm we’re not enough, that we need to give more and more of ourselves to this noble cause and, even when we have nothing left to give, we are still only mediocre. And we become exhausted, burned out, compassion-fatigued, falling deeper into our eating disorders—or depression or suicidality.
But, when we open our eyes to this, our options are not simply "do I stay and remain ill or leave and become well?" We have a third option: We can choose to reject the elements that resonate with our sick internal dialogue and stay and fight for health in both domains.
Working in medicine should not be incompatible with maintaining our own health. We can create a work environment in which we have boundaries and in which good work is acknowledged and appreciated. In this type of environment, both clinicians and patients do better because the providers can show up as whole people. We have a choice. We can break the rules and challenge both. As doctors, we can heal our sick culture, starting with ourselves.
We are conditioned to be productive all the time, and we perpetuate this when we encourage everyone else to rest but refuse to lead by example and do so ourselves. We think behaving like this means we’re keeping up, but we’re actually reifying a sick system that leads to a profession with one of the highest suicide rates in the world.
Unless we challenge this, we will continue to promote secondhand perfectionism to everyone around us—our colleagues, our friends, our children. Allowing ourselves non-productive time will feel uncomfortable and will leave a void. But we can fill this void with life—with relationships, friendships, interests outside medicine, or food and exercise. We can diversify the pie charts of our lives and in doing so become whole people once more—three-dimensional, proper people; not paper conformist cut-outs.
Things are getting better. In the last few years, there has been a definite move to support well-being and resilience initiatives in health care in the UK—these are already well established among nurses and are slowly seeping into the medical community too.
As doctors, we must take responsibility for initiating change. We can lead by example, have breaks to eat, and ensure our juniors feel well supported. We can take holidays, develop interests outside our work, and build strong family and social support networks. We can show it is OK to talk about emotionally challenging situations, and that we have permission to feel sad, or traumatised, or frightened, or guilty ... or just to feel. We can encourage those around us to practice self-care by taking care of ourselves, and gradually build a kinder, more self-compassionate culture.
These issues are not unique to medicine. The vast majority of eating disorder patients are in high-intensity jobs or following challenging academic pursuits—the great equaliser is the temperaments we bring genetically and the pressure we feel and can’t help but bow to externally. We all need to realise that we can be a wonderful version of whatever it is we want to be, but we need to be able to resist the forces that are telling us to give up everything else that matters, including our self-care.
During the earlier years of my training, I rarely switched off. I would stay late at work, come home and study for postgraduate examinations until late in the evening, or work on writing papers, presentations, grant proposals, or maintaining a pristine professional portfolio. My weekends were spent catching up on advances in research or reading journals. Yes, I received praise and external validation. But I was exhausted. And I was miserable, and I was sick.
Giving myself permission to step away from the conveyer-belt of frenetic over-achievement has not been easy—rest does not come naturally. It is all too easy to resort to the old familiar patterns of overwork, but reframing this as a proactive act of rebellion, a sign of strength rather than weakness, remembering the importance of positive modeling to my children, and seeing how much better I am as a doctor and as a person when I take time to recharge—all of this reminds me that it’s not only worth it, but that there really isn’t any other way.
“If we acknowledge our boundaries and our own needs, even with a bit of grief because we all wish we were wonder-woman, eating disorder recovery fits right in. And life fits right in. Taking the rest we truly need and standing up to a toxic culture can become an act of rebellion. We can make changes—but we need to start with ourselves.” —Jennifer Gaudiani, M.D.
Because, if we’re really honest with ourselves, this isn’t about being a good doctor. It’s not about our patients. It’s about trying to measure up to aberrant values in an outdated culture or—if we dig deeper and are even more honest with ourselves—it’s about trying to measure up to our own sick internal yardstick of what we need to do to prove we’re ok.
We must resist the pressure to be perfect. We must stop looking for external validation and judging ourselves by our achievements, and accept that we are enough just by virtue of being. We need to look at our true values and ensure we are channeling our energies in ways that align with these. Nobody is going to put your resume on your tombstone or remember you by your ORCID ID. The legacy we will leave behind will be based on our relationships, our families, our friendships, and, in work, the acts of kindness we perform for our patients and our relationships with our colleagues. And, in the interim, we will be able to experience life.
Cavedini P, Bassi T, Ubbiali A, et al. Neuropsychological investigation of decision-making in anorexia nervosa. Psychiatry Res. 2004;127(3):259-266. doi:10.1016/j.psychres.2004.03.012
Tchanturia, K.; Campbell, I.C.; Morris, R.; Treasure, J. Neuropsychological studies in anorexia nervosa. Int. J. Eat. Disord. 2005, 37, S72–S76.