Codependency is an emotional and behavioral condition historically linked to a dysfunctional relationship involving a chemically dependent spouse or family member¹ or a dysfunctional family of origin.² Over time, this concept has broadened to include exposure to a significantly stressful event, environment, or relationship that causes individuals to become externally referenced and overly focused on the needs and expectations of others.³ As a form of maladaption, their happiness, fulfillment, and self-worth can become dependent on their ability to help, care for, or please others, and eventually they may become unaware of their own feelings.^3,4

HOW CODEPENDENCY MAY DEVELOP AND BE REINFORCED IN PHYSICIANS

Prior to a medical career, some physicians may have grown up in a dysfunctional family or a challenging environment, or they may have experienced a difficult relationship. To cope with their circumstances, they may have assumed a “caretaker role.”⁵ This role may serve as a catalyst for drawing them to medicine, particularly the relationship-focused specialties.

The literature on codependency commonly describes those affected as hard-working, determined, and selfless. Medical education, training, and its rigors may attract these individuals.³ The challenges they face may spur a “survivalist” mindset, encouraging students or trainees to adopt an “always-do-better” mentality.⁶ They may put others’ needs and wishes ahead of their own, making it difficult to understand and process their own emotions. They may also focus on grades, scores, feedback, and other tangible measurements as proof of self-worth and value.

Once physicians begin a career in medicine, these survivalist behaviors are often reinforced by challenging workloads, stressful interactions with patients and colleagues, and long hours. Starting early, working late, skipping breaks, and focusing on the patient and the system at the expense of the individual is often encouraged because it improves the bottom line. This culture can lead physicians to judge their self-worth based on productivity, patient satisfaction, supervisory evaluations, and other materialistic and experiential ideals. Decreased self-esteem and self-confidence are common results. In addition, in environments where financial and productivity-based incentives counter patient-centric values and care, physicians commonly suffer from moral distress, emotional exhaustion, depersonalization, and loss of pride in one’s work, the hallmarks of “burnout.”^7,8

HOW TO OVERCOME THESE BEHAVIORS

The following tips may help physicians address codependency in a professional context.

1. Acknowledge the problem. To overcome codependent behaviors, you must first recognize them in yourself. Reflect on your upbringing, significant relationships, medical training, and work habits to identify unhealthy patterns, their origin, and potential triggers. Seek the help of a mental health professional to address these issues and any associated problems, such as stress, anxiety, or depression.

2. Understand this is not your fault. You do not own complete culpability for these behaviors. They were developed as a survival mechanism and bolstered over time by the myriad pressures of medicine and life. Don’t victimize yourself. Instead, focus on changes you can make for the future.

3. Strengthen your communication skills. You must get comfortable with direct and honest communication in both professional and personal settings. For example, you may need to communicate why a particular medication a patient wants is inappropriate, or why a nurse’s pattern of behavior is not acceptable. It is equally important to communicate well with your spouse or family regarding your daily goals, challenges, and stressors.

4. Set professional boundaries. Boundaries help define what you are and are not responsible for. With good boundaries, you will have an easier time saying “no” to requests that are outside your limits. In general, refrain from taking care of things within someone else’s boundaries and instead focus on what is within your own boundaries. Identifying and setting boundaries requires self-awareness, self-esteem, honesty, and direct communication with others. If you find yourself feeling frustrated in a certain situation or relationship, you likely need to set or reinforce a boundary.

Consider four key boundaries:

• Physician-patient boundaries. Understand the distinction between supporting patients versus taking responsibility for their health, compliance, and outcomes. As a family medicine physician, it is easy to internalize patients’ successes and failures. However, remember that you are simply a coach, advisor, and advocate. You cannot and should not bear the weight of patient choices and outcomes, as they are largely beyond your control.

• Physician-physician boundaries. You have likely experienced a time when a physician colleague crossed a boundary. For example, a consultant may have overstepped into a patient’s primary care or a colleague may have questioned your management of a patient or undermined your decision involving staff. To keep these instances from reoccurring, you will need to use direct communication to delineate or reiterate the boundary in a professional way.

• Physician-nurse/staff boundaries. Well-meaning, highly productive physicians may blur boundaries and overstep into the clinical purview of support staff. While this may be admirable, it is not sustainable. As a physician, you need to get comfortable delegating tasks and communicating expectations to nurses and staff. Once you are utilizing your team to the fullest extent, with everyone practicing to the top of their license, you can refocus your energy on your own aspects of patient care.

• Physician-supervisor boundaries. You must be able to compartmentalize your work and understand what is essential for appropriate, safe patient care and what is not. If a supervisory decision or organizational initiative impedes what is essential, that is the time to voice your concerns, offer constructive feedback, and share your opinions with your supervisor or leadership chain.

5. Relearn wellness and work-life balance. The culture of medical training and practice can easily lead you to center your energy on patient care and productivity at the expense of your own wellness. To refocus on your physical, emotional, and spiritual health, start with the basics — a balanced diet, exercise, good sleep hygiene, spiritual practices, and healthy relationships. The other key is finding ways to not bring work home. Of course, this is not always feasible, such as when you are on call. However, there are strategies for reducing “work after clinic,” such as team delegation, EHR optimization, and message management.⁸ When you are at home or on personal time, focus fully on non-work activities. It may be helpful to perform a self-care activity after work, such as going for a walk, to help you transition from work to home.

6. Let go of perfection. Seeking perfection in yourself, others, or your work can leave you feeling empty and helpless because it is unattainable. Instead, seek acceptance. This requires being comfortable with where you are in your life, training, career, relationships, or other circumstances, even while you strive for something better. This applies to your relationships with others as well. As a physician, you must teach and motivate patients and treat them to the best of your abilities while accepting where they are in their own personal health journey. Likewise, learn to accept where each of your team members are in their personal journey.

This shift in mindset can provide a sense of healing, understanding, calmness, and ease in your interactions. Instead of worrying about how to make everything perfect for the future, simply enjoy where you are today.