From the inside, it almost never seems that anything has changed. Those who live with the physician usually see it first. A psychiatrist writes about that distance.
A physician told me that her twelve-year-old daughter had asked why she had stopped laughing at jokes over dinner. She did not know how to answer. She had not noticed that she had stopped.
These sentences arrive in various forms, and they almost always come from outside. The spouse who says you have seemed different. The old friend who mentions it has been a while since you called. The resident who asks, a little awkwardly, whether everything is all right. Each of them tends to be received the same way: with “everything’s fine, just tired” — said sincerely, because from the inside that is exactly what it looks like.
That is the point I wanted to talk about. From the inside, it almost never looks as though anything has changed.
Not because the physician knows less about the subject — he usually knows more than almost anyone. When he describes what he has been feeling, he uses precise vocabulary, organizes the symptoms, would recognize that picture in any patient who sat down in front of him. And still, applied to himself, the same knowledge simply does not work the same way.
Perhaps someone has already said something similar to you. Or perhaps you are thinking now of a colleague, and wondering whether you should say something to him.
Either way, this text is about that distance — the one between what is visible from the inside and what has already become visible from outside.
From the inside, everything looks like continuity
Those who study this have a formulation that strikes me as exact: the passage between being exhausted and being ill is far blurrier from the inside than from the outside.
There is no day on which something changes category and an alarm goes off. Each week seems a reasonable extension of the last. Tuesday’s tiredness is explained by Monday’s shift; Thursday’s irritability by a bad month; the sleepless night by coffee taken late. Each piece in isolation has a plausible explanation, and so the whole series is never read as a series.
And three things in medical training make this harder still — all of them, in origin, virtues.
The measuring stick is displaced. Someone who spends the day facing acute suffering compares his own exhaustion with the patient on the ward, the oncology case, the accident at three in the morning. In that comparison, what he feels never seems large enough to deserve attention. This is not a choice — it is what happens to anyone exposed for years to that reference point.
Pushing through was trained as a virtue. The whole of training rewarded carrying on: the thirty-six-hour shift, the exam after a sleepless night, the colleague who did not call in sick even when ill. The capacity to function badly and keep functioning was built deliberately and rewarded for years. It does not switch off when the cost gets too high. On the contrary: that is precisely when it activates.
Diagnosing requires a distance that does not exist toward oneself. The physician is good at it precisely because he looks from outside, with the detachment that allows the whole to be seen. Turning that instrument inward is like trying to point an ophthalmoscope at one’s own eye. What ends up happening is a silent substitution: instead of perceiving, the physician explains.
Those who live with you hold information you do not have
There is a finding usually read as a consequence that may be worth reading differently.
Nearly three in four physicians report that exhaustion has already damaged their closest relationships. This usually appears in conversation as the price one pays. But it is also, and chiefly, clinical information — because it means the people around you are seeing something.
They notice first for a simple reason, and not because they are more perceptive: they have access to a comparison you do not have. They know the person of three years ago and compare him with the person of today. You, from the inside, have access only to the present and to a narrative that has already settled around it.
When someone who loves you says you have changed, that is not an opinion about your character, nor a reproach, nor an exaggeration. It is an observation made from the only angle from which the change is visible.
You do not have to agree with that person. But it may be worth considering that she is seeing something real — and that the difficulty in seeing it is not a failing of yours, it is the position you are standing in.
Why the difference matters
There is a concrete reason not to leave this question open for too long, and it is not a dramatic one.
Exhaustion tied to working conditions and a condition that now runs under its own power do not follow the same course. The second does not improve because the rota improved, because the holiday arrived, or because the department hired more staff. It has taken on a life of its own, independent of what started it. Knowing which side one is on is what changes what needs to be done — and that is a clinical question, answered with someone, not alone.
It is worth saying too: even a physician’s assessment of his own performance tends to be too generous. Almost half of those who describe depression say it does not affect their contact with patients — while every indicator of impatience, carelessness and irritability rises in the same survey. This is not dishonesty. It is the same difficulty of looking inward, operating again.
On why it is hard to recognize
When a physician cannot recognize his own state, there is almost always something at stake beyond a lack of information.
Recognizing it would mean admitting something about himself that an identity built over decades does not easily accommodate. A great deal was invested there — not only hours, but the idea of who one is. That is not dismantled by an effort of sincerity on a Sunday afternoon.
This is why a space of personal analysis tends to be useful here, and it is worth being precise about what it is: not a self-monitoring technique nor training to pay closer attention to one’s own signals. It is a place where the relationship to work can be examined slowly, with someone occupying the outside position no one can occupy toward themselves.
If someone has already said this to you
Nothing has to be decided now. Neither agreement, nor being convinced that you are unwell.
Perhaps only this, kept somewhere: if someone who loves you has been saying that something has changed, that information is worth more than your own assessment of the matter. Not because she understands medicine — but because she is standing in the only place from which it can be seen.
And if what came to mind while you read was a colleague’s face rather than your own, that counts too: sometimes a sentence said with care is the most useful thing one person does for another all year.
Related reading
- The physician who becomes patient: when the narcissistic wound is the greater resistance
- Doctor: the fear that asking for help will cost you your career
- When the physician is the one who needs help
Has someone close to you been saying you’ve changed?
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Dr. Leonardo Sodré is a psychiatrist and psychotherapist in Brasília, Brazil (CRM-DF 14.206 · RQE 14.761). He holds a PhD in Psychiatry from UFRGS and teaches at the University of Brasília School of Medicine. This content is informative and educational and does not replace individual assessment, diagnosis or treatment.