Le rapport à la garde comme objet interne chez les médecins hospitaliers publics, entre toute-puissance et toute-impuissance

Abstract

Objectives

This study adopts a psychoanalytic approach to investigate the conscious and unconscious relationships of French public hospital physicians with on-call duty (garde), which is conceptualized as an internal object as per Kleinian theory. The aim was to understand how this internal object evolves over the course of a physician's career: from a “good object” supporting medical narcissism to a persecutory “bad object.”

Methods

The data come from a broader qualitative study commissioned by the Fédération Hospitalière de France and were obtained via 44 semi-structured interviews with public hospital physicians. For our research, we selected a subset of six participants (three women and three men for gender parity, all aged 34–56, with medical specialties requiring on-call duty, such as anesthesiology, critical care, pulmonology, and emergency medicine). We employed three criteria: physicians had (1) regular on-site night duties; (2) status as a senior hospital practitioner in somatic care; and (3) explicit or diffuse anxiety linked to on-call duty. Interviews were transcribed and included information on verbal and non-verbal cues. Their content was analyzed using a clinical-qualitative approach, and we cross-referenced narrative material with psychodynamic theory. The goal was not thematic coding but the identification of the forms taken by internal objects, with a focus on “on-call duty” as an internal object.

Results

Early in their careers, physicians tended to have a positive investment in on-call duty, which may even have been viewed as a coveted professional experience. It was valued as an opportunity for accelerated learning, autonomy, and symbolic recognition, where the undercurrent was a defensive yet functional fantasy of omnipotence. Narcissistic gratification coexisted with anticipatory anxiety (centered on fears of incompetence), which was often contained by recourse to “the Other is supposed to know” (senior colleagues, peer networks), functioning as a psychic and institutional pare-excitation. Over time, however, the balance shifted. Physical exhaustion, chronic sleep disruption, intrusions into personal life, and the erosion of symbolic rewards transformed on-call duty into a persecutory “bad object.” Fueled by a harsh, overdemanding medical superego, feelings of guilt emerged, which were rooted less in clinical error than in the perceived inability to provide optimal care under degraded conditions. Institutional recognition, both financial and symbolic, was experienced as insufficient, intensifying archaic experiences of helplessness (Hilflosigkeit). The protective fantasy of omnipotence could collapse into a fantasy of total impotence, with two defensive outcomes: (1) resignation, loss of meaning, and relational withdrawal or (2) rigidified hypercontrol and excessive performance demands, engendering a risk of burnout.

Discussion

Our findings fit with prior results from research on the psychic costs of hospital medicine: repeated exposure to death, urgency, and solitary decision-making threaten to erode the medical narcissism that sustains professional identity. On-call duty, as an internal object, condenses these dynamics. Initially a reparative omnipotent object, on-call duty may become — when institutional scaffolding fails — a source of trauma where omnipotence turns into impotence. In Kleinian terms, the physician's capacity to integrate the “good” and “bad” aspects of on-call duty is challenged; instead, splitting, denial, or rationalization may prevail. The institution, in which physicians may become unconsciously invested as they would in a “good-enough mother” (Winnicott), is experienced as failing in its function as a container, amplifying feelings of abandonment. Here, we draw upon Ferenczi's notion of trauma repetition (1916, 1933) and hypothesize that there may be symbolic traumatophilia: the paradoxical attraction to on-call duty may — if adequately supported — serve as a means of gradually working through archaic anxieties. Conversely, without adequate support, this repetition risks becoming a self-calming defensive procedure, reinforcing dissociation or functional splitting between a professional “false self” and a vulnerable “true self.”

Conclusions

Understanding on-call duty as both a psychic object and institutional stage highlights the broader conflict between caregiver subjectivity, the reparative drive, and the organizational realities of public health systems. This perspective invites the presence of psychological support as well as of institutional and symbolic support that are aligned with physicians’ expressed needs. By acknowledging the ambivalence and potential symbolic function of on-call duty, interventions can move beyond burnout prevention and focus on fostering conditions for genuine subjective transformation.