Heinz Kohut and Identity

Why Physician Burnout is Actually a Loss of Professional Identity

By Timothy Lesaca, MD | 

Most accounts of physician burnout begin with a familiar list: too many hours, too many clicks, too many patients, and not enough time. The diagnosis follows easily: Doctors are exhausted. Something inside them has been used up. Burned out. That explanation has the advantage of being familiar, but it also has the potential to be incomplete. There is another way to understand what is happening, one that comes from an unlikely place.

The Self and its Supports: The Theory of Heinz Kohut

In the 1970s, the psychoanalyst Heinz Kohut revolutionized our understanding of the "Self" through what became known as Self Psychology. He proposed that a person’s sense of self is not a self-contained engine that generates its own power. Instead, the Self is a dynamic structure that requires "psychological oxygen" from the environment to remain intact, vibrant, and cohesive.

Kohut was interested in how people remain themselves over time—not just functioning or performing tasks, but experiencing their actions as a continuous, meaningful expression of their internal values. He argued that this psychological health depends on a set of external supports he called Selfobjects. These are not "objects" in the physical sense, but functions provided by our environment—our institutions, our mentors, and our work—that we experience as part of our own internal scaffolding. When these functions are present, the Self feels strong and ambitious; when they are withdrawn, the Self begins to undergo "disintegration anxiety," a quiet but devastating internal crumbling.

The Three Pillars of the Professional Self

Kohut described these essential supports in three specific ways, each of which is being systematically stripped from the modern practice of medicine:

• Mirroring: This is the environment’s role in reflecting back a person’s sense of competence and worth. For a physician, mirroring occurs when clinical judgment is respected and when the complexity of their work is acknowledged. It is the "gleam in the eye" of the system that confirms: What you see and what you decide matters.

• Idealization: This is the need to belong to something "greater"—an idealized, stable, and ethical "Other" (such as the Medical Profession or a Great Hospital). This connection provides a sense of security and calm. If the physician can respect the system they serve, they can draw strength from it.

• Twinship (or Alter-Ego): This is the essential experience of "likeness." It is the sense of being a human among humans, a doctor among doctors, sharing a common language and a shared destiny. It provides the comfort of not being an isolated cog, but a member of a recognizable community.

These are what allow a professional identity to hold together over time. Without them, the Self does not just get "tired"—it becomes depleted and fragmented.

The Gradual Erosion of Professional Identity

Historically, medicine provided enough of this structure to sustain physicians. Clinical judgment carried weight. Institutions, though imperfect, could be relied upon as stable anchors for one’s career. Colleagues were not just coworkers but recognizable participants in a shared role. It is harder to say that now.

A treatment plan may require approval from someone who will never meet the patient. Authorizations delay care, though responsibility for those delays is diffuse. Documentation expands, but not in ways that clarify thinking or improve decisions. None of this is surprising in isolation. Each step can be justified. But taken together, these changes begin to alter the conditions under which physicians practice in ways that are difficult to name, yet deeply felt.

Kohut would likely have recognized the pattern, not simply as inefficiency, but as a systematic withdrawal of Selfobject supports. If your judgment is constantly "overruled" by an algorithm, the Mirror is broken. If the institution prioritizes margins over the mission, the Idealized anchor is lost. If you are treated as an interchangeable "unit of productivity," the Twinship vanishes.

When Burnout is Not Just Exhaustion

Something else shifts as well, though it is less visible. In Kohut’s theory, when the Self is not sustained by its environment, it protects itself through "defensive fragmentation." Engagement becomes more selective. Points that once felt essential are weighed against whether they will meaningfully change an outcome.

From the outside, this may resemble disengagement or "cynicism." From the inside, it reflects a desperate internal recalibration. Burnout, in this light, is not a state of being "used up"; it is a state of being "diminished." It is the psychological result of trying to maintain a cohesive professional identity when the environment no longer reflects that identity back to you. The exhaustion is not from the work itself, but from the immense psychological energy required to hold oneself together in a system that treats the "Self" as irrelevant.

This is why physicians often say:

“This is not how I expected to practice.”

“I spend more time navigating the system than caring for patients.”

“I am not sure what kind of physician this is shaping me to be.”

The work continues. Patients are seen. Tasks are completed. Nothing has obviously failed. Yet a subtle misalignment can emerge between the physician and the conditions of practice. A person can tolerate significant difficulty if their work still feels like a coherent expression of who they are. When that coherence weakens, something more fundamental is affected. The physician remains. The role remains. But the connection between them becomes less stable.

Rethinking Our Response

This helps explain why many responses to burnout feel incomplete. If the problem is framed as stress, the solution becomes stress management. If it is framed as fatigue, the response is rest. If it is framed as a lack of resilience, the response is training. Each has value, but none address whether the environment still supports a meaningful alignment between physician and practice.

Kohut did not write about health care systems. But his framework points in a clear direction. If physicians are to remain present in their work, the structure of that work must meet them in specific ways. It must reflect their judgment as meaningful. It must be sufficiently stable to rely upon. It must allow for a sense of shared professional identity rather than isolated adaptation.

Without these conditions, physicians do not necessarily stop working. They continue, often competently, even exceptionally. But over time, the work draws on a narrower and narrower portion of who they are. If burnout is understood in this way, it will not be resolved by asking physicians to better endure conditions that steadily narrow their role. It will require attention to the conditions themselves: how work is structured, how decisions are mediated, and whether the practice of medicine still allows physicians to experience what they do as a coherent extension of who they are.

The work will continue with diminishing alignment between the physician and the practice of medicine, or, more simply, with less and less of themselves.