Here is the corrected transcript with Dr. Raja's first name updated to "Annia" throughout:
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This is the Drive Time Debrief, episode 211.
Hey guys. Welcome back to the podcast. I'm Amanda. I'm Laura. And I'm Kendra. And today is special because we are joined by Dr. Annia Raja, a clinical psychologist who specializes in working with high achieving professionals, especially physicians who are navigating anxiety, burnout, perfectionism, and the emotional challenges that often accompany demanding careers in medicine.
Dr. Raja has more than a decade of experience helping physicians explore the deeper roots of burnout, including guilt, suppressed emotions, identity struggles, and the pressure to constantly perform. As both a therapist who works closely with physicians and someone who's married to a physician herself, she brings a unique perspective on the personal and relational toll that the culture of medicine can create.
Oh boy. Preach. Today we'll be talking about burnout, emotional suppression in medicine, and how therapy can help doctors reconnect with themselves and create more sustainable, meaningful lives. Thank you for joining us, Dr. Raja. Thank you so much for having me. I'm very excited for our chat today. This is exciting.
I know that you're gonna bring an amazing perspective, not only because of your background and your expertise, but that you get to go home and experience it too. So this is gonna be fun. Yes. So you say that you work closely with physicians in therapy. What do you find are the most common struggles you see doctors facing when they first come to you?
Oh man, so many. Where to start. I mean, I think the lowest hanging fruit we could pick at is burnout. You know, obviously that term and phenomenon is in the broader cultural zeitgeist. I don't like that term. I'm sure we'll kind of get into that as we start to talk, but sure, that's, you know, an easy
concept for people to grab onto that brings doctors to therapy. I think kind of at a deeper level beneath that it's really a constellation of concerns both at the surface level and then all these kind of concentric levels underneath. So at the surface level, you can see things like anxiety, whether it's, you know, a DSM diagnosis or not.
Again, I don't think too diagnostically about things, but sure, I'm feeling anxious all the time, or it's hard for me to turn my mind off. Perfectionism shows up a lot for people. For some folks they can have a more overt experience of, you know, classic depression where, you know, everything just feels like a
slog. There's just a constant gray cloud over everything, both in work and outside of work. I think at deeper levels, and this is kind of really more the bread and butter that I get really excited about. And again, these things are all interconnected as we'll chat about, but, you know, struggles with identity and self-worth.
I think there's a strong kind of strain of whether people are able to put words to it or not, but the sense of like, who am I outside of medicine? Like medicine has just consumed my entire waking, living and being, and there's either this sense of I've lost touch with who I am outside of my doctor identity, or and I think this can be even more uncomfortable and distressing for people, I haven't really fully developed that part of myself, right? There really has been an underdeveloped sense of, and a difficulty contending with what it even means to be a full whole human being outside of that doctor role. I think relationship concerns certainly bring people in, you know, so both thinking about it clinically as well as through the prism of my lived experience of being the spouse of a physician, it's not just you that's impacted, it's all of the concentric circles of your relationships, whether you're partnered or not, whether you have children or not. Your broader sense of community. Either strained relationships, underdeveloped relationships. There's again, also other constellations of experiences like
heightened irritability, cynicism, a sense of not even knowing what you feel. That's also, I think, a really big theme that shows up for people, and I think people can often struggle to even name this. There's been a globalized sense of just utterly losing touch with even the capacity to feel.
But those are some of the kind of high level hallmarks that show up. Yeah. And I'm sure there's more that'll come to mind as we keep chatting. I think you just played a highlight reel of the first half of my career.
I was like, I feel very seen and called out at the same time. So cute. I'm not sure what to do right now. Thank you. That was so much validation in just that one simple answer to the question. We knew that you were gonna be amazing. So many people and doctors think that burnout is simply just working too many hours.
And we talked about this just recently actually on our social media. But really the number of hours and the obvious physical workload isn't everything. From your perspective as a therapist, what's really going on beneath the surface when physicians start even experiencing symptoms that they may not even be attributing to burnout, but some sort of symptoms, maybe they're off, or maybe they're just physically, emotionally, spiritually tired and they're just not sure why?
Yeah, so this is where I think it's so important to bring in the macro alongside the micro. I think the phenomenology of burnout is frankly just too individualized in the way that we talk about this. And we try to atomize
physician burnout as somehow an individual problem when I think in fact, this is a deeply systemic, deeply structural, deeply cultural problem. And I don't mean just the culture of medicine, I mean the culture writ large of living in America. And so I think, you know, what types of ways
does burnout show up for people? It shows up in all of those layers. And so, yes, you get the cynicism, you get the emotional numbing, you get the suppression. Other factors that contribute, I think a big one is moral injury. So I think that really tethers with needing to think structurally and systemically about things.
You know, just as an example of, again, so many that we could talk about, anecdotes and, you know, I'll obviously de-identify things, but a huge theme that is showing up with a couple of my physician clients these days is actually the moral injury of dealing with insurance companies and them denying first line, mainline evidence-based treatments and literally causing harm
to their patients, and physicians end up being the frontline kind of bearers of that brunt. I heard this analogy a while back around burnout in medicine in general that I think is really apt. We tend to think of medicine, if you think about it, as a soccer field, right?
There's different players. They're on different parts of the field. And then you have the goal, and then you have the goalie on either side of the goal. The physicians are basically the goalie, and what we tend to conceptualize, you know, these problems in medicine as is, it's all the goalie's fault.
It's all the person who's right at the front lines, whether they stop the goal or whether they let the goal in. And it's totally neglecting the entirety of the field. And so I think that analogy is really apt for us to try to get a deeper and frankly, more mature and realistic understanding of the contributors of burnout.
And intersecting with that, how it shows up for physicians. Moral injury is a huge one. I think another one that isn't talked about as much, particularly among physicians, and needs more spotlight is trauma exposure, like repetitive vicarious and direct trauma exposure. And you don't have to be just working in an ER or in a trauma setting to have traumatic exposure.
And so even with that, bringing in a prism of a PTSD diagnosis is incomplete. If you look at the trauma field, in the current landscape we're shifting more to a complex trauma etiology and phenomena where it's not just like one singular event that's causing injury.
It's the repetitive nature of traumatic exposure and traumatic injury that's leading to a wide variety of, whether you wanna call it symptoms or diagnoses or, you know, I prefer more language around human injury and the phenomenological and existential injuries and wounds that come with that.
I imagine I've probably lost track of your question, so if you could even like reorient me back, kind of more like, how does burnout present? That was kind of where we started, right. Yes. So I think the other things to mention with that too is loss of autonomy and just the bureaucratic strain.
Yeah. I think just like you said, we are taught to suppress because we sustain and see and treat so many worst case scenarios and then are supposed to go in the next room and do it all over. And so I think that was a really good point to say, we were never trained appropriately, we're never told the things you are telling us now from the beginning and wow, what would that have been like?
Just even that sheer validation, like this isn't just on you. Yeah. Mm-hmm. Yeah. So piggybacking on that, we're taught to be tough. We're taught to suppress, we're taught to compartmentalize, you know, patients first. And you know, really carrying around that level of emotional labor day to day. It just really compounds.
So how do you see that affecting physicians over time in our culture, our emotions, our spirit, everything? Yeah. Oh man. So many ways. I think the first place that my mind goes is kind of like you said. Medicine reinforces these schemas and beliefs and pressurizes them even further.
Right? That, you know, you don't have room to feel. There's no time for it. There's no space for it. Oh, guess what? There's three patients waiting for you. And I think that's some of what's so hard and difficult about it is that no one wants a doctor who's gonna be crumbling under the pressure. Of course not. So again, it's adaptive in certain settings to be able to contain and to compartmentalize and be able to move through your day. The problem is, one, when that tendency gets globalized, and two, when there isn't a release valve for all that compartmentalization, right?
And so I think both of those frankly show up for people where they're either working so much, right, whether it's in residency or otherwise, that quite literally from a time and just limits of human existence, there's literally not time to even be able to have a pressure valve release.
But when there is that space, it doesn't get prioritized or it's not validated. I think the kind of deeper thing that I often talk with my clients about is there is one reality that we as humans cannot escape. And that is that we as humans are not capable of selective numbing.
That's just not possible. Okay, so I have to explain this a bit. So if you'll bear with me. So we're not capable of selective numbing. So what does that mean? We either numb or we don't. Okay. So if we have certain areas in our life where numbing shows up, whether it's adaptive or not, there is a high risk of that getting globalized across
the entirety of our life, our existence, our identity. And so when we get into patterns and dynamics of numbing one set of emotions that we find uncomfortable, painful, distressing, annoying, like, eh, I don't wanna deal with it. Right? And those avoidant tendencies. The reality is that that dynamic gets globalized to the full spectrum of human emotions.
So what ends up happening over time is you're also numbing yourself to the capacity for joy, for contentment, pleasure, happiness, fulfillment, and everything in between. And so if we want, if we're feeling frustrated with like, God, I'm just not happy, or I am struggling to feel fulfilled, etc., I often have to talk to people about how we're gonna have to slowly
work on feeling those things that you've just been putting in the back dumpster for a while, if we're gonna have any potential to increase your capacity for these things that you find yourself yearning for, but just feel like they're out of reach. In our training there was the idea that there was no time for feelings because we're taking care of other people. And I like that you pointed out that it's normal to compartmentalize.
The problem is when we come home and we still can't feel, and we still can't connect with the people that we love, like what is life really about at that point? So thanks for bringing awareness to that. You mentioned themes like guilt, perfectionism, and this fear of not being enough that often show up in therapy with physicians.
How do these patterns develop in medical culture? Well, yes, they certainly develop in medical culture and I think they usually go even further back for people. There are kind of several clusters that I think show up for people. I think one is that helper identity usually develops much earlier in life.
And so just as an example, you know, I love getting into family of origin dynamics with my clients, like what was your family environment and your family system like? Were you, for example, parentified, where at a very young age you were expected to not only be an adult, but not have any childhood or childlike emotions and the developmentally normal kind of progression through what it means to be a child.
Like you were put in a parent role really quickly, whether it was for siblings or whether it was for one of your parents where, you know, there's this sense of like, I gotta take care of mom, or I gotta take care of dad. That really commonly can also intersect for people around martyr complexes too, where there's this intersection of like,
in order to hold onto an identity, a self concept of I'm a good person, and also really clinging really strongly to that. Like, I have to be a good person as opposed to what, you know, one thing that I love working on with people in therapy is that we have good and bad and complex and nuanced within all of us.
Like having a richer, more nuanced and more textured self-concept beyond clinging on to like, I just gotta be a good person. So for some folks there's a really strong clinging to like, in order to be a good person, I have to constantly be self-sacrificial. I have to be giving, I can't receive, forget reciprocity.
Even just any sense of like, mutuality in relationships is either neglected or underdeveloped or suppressed. And I think all of these deeper tendrils influence even the type of people who go into medicine, right? Mm-hmm. And then it's really easy, I think structurally and culturally for the broader
social zeitgeist to take advantage of that, and then of course, medical culture just piggybacks on all of that, right?
So you gotta be perfect as far as your grades, your boards, in residency, you can't make mistakes. If you do make mistakes, you better learn from it immediately and there's no processing it.
And then on top of that, I think one curious thing that I see in my practice, I think this intersects with some of what you're talking about, is that there can be, you know, throughout med school and residency, there can be this kind of light at the end of the tunnel that someone's holding onto of just like, okay, I just gotta get through med school.
It'll be better. Let me just get through these last couple years, plus or minus fellowship. And then once I'm an attending, it's gonna be so much better. The arrival fallacy? Yes. Guess what? That is not what happens for people. Wherever you go, there you are. And I think that's actually a common pattern that I see in my practice. I have people reach out like three to five years into attending life where they may have kind of held onto that,
just like, all right, I'm an attending now. Like, okay, fine, there's some early career kind of bumps, but okay, it's gotta get better, right? It's gotta get better. And then slowly, the reality sets in. It's like, oh shit.
And so I say all of that to say that these things really run deep for people and I think doctors can really struggle with this externalizing impulse too, of just like, okay, my setting's gotta get better. Yes, all of that's real. Again, let's hold a both/and around it. Like the setting is absolutely part of the structural problems that we're dealing with, and we have to also deal with you.
Yeah. I'm really glad that you said that because I have often said that we come into medicine, which to my mind is a huge narcissistic family system. Oftentimes we come because it felt familiar and
it's not just the helpers who go into medicine. There's the other side of that coin, which is the more dominant personality. The people with more dominance in their character traits and more narcissistic features, and that's just within the system. It's not even just the health insurers that are doing it to us.
We do it to ourselves within the family of medicine. I'm just curious, you've described your work as depth therapy. Is that what you're referring to, or how is that different from simply managing stress or developing coping strategies?
Absolutely. I love this topic, by the way, so I'm glad you guys are asking this. I consider myself a depth psychologist. And I have found over the years that in trying to describe my style of therapy to folks, it's actually helpful to describe a little bit of the opposite as a frame of reference.
On the one end of the therapy spectrum, it's more like the cognitive behavioral therapy model.
CBT really lends itself to being medicalized. Really kind of on this rubric of symptomatology, diagnosis, quantifiability, etc. And there are other approaches that kind of do that too, that really focus on behaviors and thought patterns and, oh, you can just restructure your thoughts in order to feel better, etc.
And I'll just be frank, like that can have a space for maybe a certain set of folks, but I think the reality is, especially for doctors, these folks more than anyone tend to be doers and fixers already, right? That's already a default setting, guys. Like, the reality is if the types of things that brought you, guys more than anyone else, into therapy had a quick and easy fix,
you probably would've tried it already and it probably would've worked. Okay. Like fine, if you wanna go pick up a CBT manual or an acceptance and commitment based therapy manual, you can self-help your way till the cows come home. Like, fine. If it's helpful, great. But I'm much more about getting underneath the surface of things, and that does take time.
And so a depth oriented approach, I actually encourage my doctor clients to deliberately put the urge to problem solve in therapy on the shelf.
Like it can be a bit of a distraction to be quite honest. Now, again, I'm not here to tell you to suppress those thoughts. Let's just notice them when they pop up and then gently invite more of an open curiosity in our work and our relationship to actually just follow your mind to other parts that might feel less familiar.
But there's still some curiosity around, and again, a gentleness around this. I think this is a lot of the balance that a good depth therapist can help with, is we're not trying to put pressure on that system, right? We wanna stay in a therapeutic window of, you know, if you think about medication, right,
you don't wanna be underdosing, you don't wanna be overdosing. We wanna stay in that therapeutic window. And the same thing applies in therapy, and my prism to do that is just an open, curious, exploratory dynamic in our work together where things just start to reveal themselves over time. And your mind might take you to like, you know, just randomly talking about your family system or like, it might take you to a patient interaction that reminds you of a deep seated fear you have about
your future. It's infinite, right?
And so slowly as we start to just be curious together, we start to make connections over time in a way that we can't quite get at if we're constantly having this problem solving hammer at things. Right? And so I often tell people that they'll ask me like, okay, how long until I'm not anxious anymore?
It's like, I don't know, like, I don't know what's underneath your anxiety yet.
Like literally within like the second or third session, people are talking about their family backgrounds. They're talking about their sibling relationships. They're talking about fears of death and dying. They're talking about fears of being alone. All of that is grist for the mill. And you know, what I've found over the years with folks is people start to feel better.
Whatever that means, but they start to feel better, one, in ways that we can't quite predict at the onset if we had just kind of come at things from a symptomatological basis, and two, they're not even quite sure how they've gotten to a better place.
But we just know that we're on a path together now. Sure, I could conjecture and be like, well, it's because we're talking about these, you know, x, y, z things that have been neglected for so long or not. But yeah, that's in a nutshell, kind of what depth work looks like working with someone like me.
So there is a stigma around physicians seeking therapy sometimes. Do you think that that stigma still exists? Is it getting better? And is there anything we need to do to begin to change it? Yes, unfortunately it's still pretty prevalent.
Some short bullet points come to mind. One, just to even speak to the structural part, I think doctors are afraid to come to therapy for some really understandable reasons around
fearing licensure ramifications or board stuff, that type of thing. And it really enrages me that unfortunately there is some reality to some of those things that we have to contend with. The field does not make it easy at all. In fact, it makes it incredibly difficult for doctors to even feel safe at a minimum to reach out for help or support, and much less actively punishes and penalizes doctors at worst.
And number two, that's also another reason why I don't work directly with insurance companies, as far as being in network with anyone. They'd require a diagnosis. They can audit notes and that type of thing whenever they want. Things become discoverable versus, you know, staying on a self-pay basis.
Things are completely confidential, outside of obviously the legal stuff that we all have to be beholden to, but outside of that, everything's confidential. Working in that way, I've even had some physicians that use fake names with me because that's how scared they are. Makes sense.
These types of conversations are so important to normalize, like doctors being in therapy, doctors talking to one another about being in their own therapy, encouraging their friends and colleagues to be in therapy.
You know, having people who specialize in working with doctors. I think unfortunately that is really important and it's quite rare. Yeah, I could probably count on one hand other colleagues I know who actually specialize the way that I do. I think we've become incensed, like, how does this job not come standard with a therapist and a coach and everything, like, what in the world, what other career would be like this?
Throw people out to the wolves with no support whatsoever. No armor. Absolutely, it's wild. Yeah. Crazy. So for physicians listening who may feel burned out or frustrated, or there's just something off, like maybe disconnected, what are some early signs that it might be time to seek deeper support? I think emotional numbing is a huge signal.
Like if you just even notice, I'm saying this colloquially but also not, like if you're feeling dead inside where you're just feeling a lack of feeling, like just an inability to even have a full spectrum of emotions. I think that's a huge sign. I think another one that shows up for people,
it's either like numbing or for a certain personality type where there might be a little more active and energized kind of a personality, like irritability, anger, a really strong kind of intense difficulty, and like cynicism and just everything feels dark, but there's an intensity to it.
So you're just constantly on edge. That's another signal for people. I think relationship problems, to be quite frank, whether you're partnered or not, whether you're struggling with friends or not, or whether you're noticing and feeling the impacts of having a lack of relationships in your life.
There are all sorts of reasons that bring people in.
But the last thing I'll say with that is you don't have to be struggling to that degree to even reach out. Therapy is just a good exercise for overall wellness maintenance, independent of the severity of how much you might be struggling. I think a good analogy to this that comes to mind is, you know, exercising or going to the gym. You don't
stop exercising once you feel good. It's like, no, that's a signal that you're doing something good and well for yourself and you ought to keep doing it.
I think we need to get away from therapy is for when you're broken. Like therapy is just for humans, period. Like, here we go. Yes. So one of my pet peeves is when it was like, well, everything sucks and you're doomed. So let's talk about, let's say there is somebody who's feeling convicted and they start engaging in meaningful therapeutic work.
What does the transformation look like in their lives and relationships once they start doing this work?
Sure. Yeah. I think first and foremost what I tend to hope for with my clients is a greater capacity and tolerance for feeling, you know, really just kind of coming back to that.
So if they're able to come to session and tell me that they feel sad, I count that as a huge win. Like even that can be a struggle for people. And so a fuller capacity to feel the full spectrum of human emotions. You know, certainly low hanging fruit can look like healthier boundaries at work or, you know, just better relationships at home or in the community.
I think a deeper, like, yes, fist pump or high five that I kind of have with people is when they start to stop talking about work and they're talking about having a richer, fuller life outside of work. So talking about hobbies, talking about spending time with friends and loved ones and not talking about work when they're doing that.
You know, whether it's traveling or staying in, just carving out more time outside of work, even just to be alone, like be with yourself. Sometimes that can even be a struggle for people. So even just the ability to sit with yourself. So that's a big one. I think that also really dovetails with having a more balanced sense of self and identity.
I would love for doctors to not have that be a primary identifier for who they are if someone asks you who you are. Mm-hmm. And number two, you know, I would love for doctors to not feel like they constantly have to be talking about medicine, whether it's with or outside of colleague relationships.
So again, just a fuller spectrum of human experience, and that means good, bad, and ugly. Love it. That is awesome. Thank you so much, Dr. Raja. This has been an amazing conversation. We definitely feel heard and seen in all the things, so thank you so much for being an expert in this space because there's not enough of you to go around for sure.
Aw, you're so welcome. I'm so happy to have had this conversation and feel a tremendous sense of meaning in this work too. And so whatever ripple effects we can all kind of collectively create together, I'm so happy to see and feel it.
Dr. Raja, thank you so much for joining us today and for the important work you're doing supporting physicians' wellbeing. If listeners wanted to learn more about you or your practice, where can they find you? Is there a website or what's the best way? Absolutely. Yes. So you can find me, the main place to find me is on my website. It's a long tag, so if you guys can also put it in the show notes, I'd be so deeply appreciative. But it's anniarajaphdtherapy.com. So A-N-N-I-A raja PhD therapy.com. Folks can also email me directly at [email protected]. And yeah, it's me and my practice as well as one other psychologist who
specializes just like me in working with physicians. And the other place that folks might be interested in finding me is I'm a regular contributor to the White Coat Investor, whitecoatinvestor.com's blog, and, happy timing actually, I had a blog post that they released today.
It was just slated for publication today. So it's on money scripts and you can check that out on their website as well. Nice. Awesome. Well, thank you so much. And that's it for today. Friends, if you found this conversation helpful, the best way to support us is to subscribe. So click that button now and rate us five stars. Of course, leave us a review and it helps other physicians find us and it moves our podcast up on the list, and we'd love to hear from you.
So if you've had an experience or have any questions, email us at [email protected]. And don't forget to follow us on the socials at The Whole Physician. We love connecting with you there. And until next time, you are whole. You are a gift to medicine and the work you do matters.
