Guest Article

Therapy With Physicians: When Competence Is the Presenting Problem

Martha Fernandez, LCSW

The intake goes smoothly. Too smoothly. The new client is a hospitalist, or an anesthesiologist, or a surgeon with a full clinic and two kids. She arrives on time, summarizes her history in clinical shorthand, names her own symptoms with the right terms and asks what the evidence says about treatment. By the end of the hour you have a clear picture of everything except how she actually feels.

Physicians are often very good at being patients in the way they would want a patient to be. That competence is real, and it is also frequently the problem they have brought you.

They arrive late, and they arrive "fine"

Physicians report burnout at high rates and seek care at much lower ones. The AMA's Organizational Biopsy recorded that 43.2 percent of physicians reported at least one symptom of burnout during 2024, across nearly 18,000 responses. CEREVITY's paper43% of Physicians Report Burnout, Few Ask for Help traces that figure to its source and walks through what sits between a physician and a first appointment: licensing and credentialing questions, the colleague down the hall, and a schedule with no open hour.

By the time a physician reaches your office, the problem has usually been running for a long time. What you see in the first session is not the beginning of the strain. It is the version of it that has learned to function.

What competence hides

A few patterns are worth watching for in the first weeks:

• Diagnosis as distance. Clients who describe themselves in the third person, or in DSM language, may be standing outside their own experience. "Probably an adjustment disorder with anxious mood" is an assessment, not a feeling.
• Fast insight. Physicians often reach the interpretation before you do. Quick insight can be real, or it can be a way to close the topic before it gets uncomfortable.
• Performance in session. Some clients try to be the best patient you have ever had. Watch for apologizing for "wasting your time," or wanting homework to complete perfectly.
• Minimizing the body. Many physicians will describe sleep deprivation, skipped meals and chest tightness as ordinary features of the job.
• The colleague frame. A client may treat you as a consultant on their case rather than as their therapist, which keeps the relationship comfortable and keeps them safe from it.

None of these is resistance in the usual sense. They are the skills that got the client through training, used in the one room where they do not help.

How to slow the session down

Ask for the experience, not the assessment. "You told me what it is. What is it like?" often lands harder than any interpretation.

Name the competence gently. "You are very good at explaining this. I wonder what it would be like not to explain it." Many physicians have never been invited to stop performing.

Tolerate the silence. Physicians are trained to fill gaps quickly and efficiently. Leaving one open can be the most useful thing you do.

Go to the body. Ask what happens physically before a shift, after a death, or at 3 a.m. The body often tells the story the narrative leaves out.

Expect the test. Some physicians will check, directly or indirectly, whether you are clinically sharp enough to be worth their time. Meeting that test with steadiness rather than credentials tends to build the alliance.

Practical expectations of this population

Physicians and other high-functioning professionals bring practical concerns to the frame of treatment, and addressing them early keeps them in care.

Confidentiality, in detail. Expect specific questions about records, diagnoses and what could ever reach a licensing board or credentialing committee. Answer plainly, explain what goes into your record and why, and acknowledge the worry as reasonable rather than paranoid.

Scheduling. Early mornings, evenings and telehealth sessions from a parked car between shifts are common. Rigid scheduling is one of the fastest ways to lose these clients.

Cash pay. Some physicians prefer to pay privately so that no claim goes through an employer's health plan. Be clear about your fees and documentation from the start.

The referral network. Physicians may avoid clinicians who also see their colleagues. If you work within a hospital system, say so, and be ready to refer out if the overlap is too close.

The aim

The goal is not to strip away a client's competence. It is to make it optional for an hour a week. When a physician can sit in your office without managing the room, the work that brought them in finally has somewhere to happen.

Martha Fernandez, LCSW is a licensed clinical social worker and co-founder of CEREVITY, a private-pay concierge network of independent licensed clinicians built for high achievers, including physicians and other healthcare professionals. She is the author of Wired to Burn: A Therapist's Guide for High Achievers Running on Fumes. Website: cerevity.com.