Portal de Periódicos da CAPES

Presidential address: Balance

1999; Elsevier BV; Volume: 24; Issue: 1 Linguagem: Inglês

10.1053/jhsu.1999.jhsu24a0001

1531-6564

Andrew K. Palmer,

Postmodernism in Literature and Education

It is my privilege and honor to address you as the 52nd president of the American Society for Surgery of the Hand. I, like all my predecessors, agonized over what I could speak about that would be educational and meaningful. After reviewing the presentations of past presidents of this Society, my involvement in this Society, my experience as a hand surgeon for more than 20 years, and in particular my interest in the wrist and governmental affairs, I considered giving a presentation on the distal radioulnar joint or on health care reform. Both would have been challenging to me and relevant to many of you, but a cop-out because they would not have reflected my present passion and what I feel called to speak about today, ie, balance in our lives. As I reflected on my career in hand surgery, I realized that I have been preparing this discussion for the last 25 years. As many of you can attest, I have not always modeled, over the past 25 years, balance in my life, having been intently focused on my career as a hand surgeon. That is not to say that I have not loved my life as a hand surgeon or been successful. Believe me, if either of my children should choose to follow in my footsteps, I would be honored and would predict for them a very rewarding and satisfying career in medicine. I am convinced, however, that I would have been happier and more successful in medicine and in life had I been more balanced. It is about this type of life or road that I wish to speak to you today. It is important that I point out at the outset that little of the information or the ideas that I will share with you is new or, for that matter, original with me. For many, this talk will be a reminder to help keep priorities in line. For others, it will be an awakening. For myself, throughout my entire career I strove to keep my career in balance with family, physical and emotional health and stability, and my overall happiness. I did reasonably well. Although I have recognized for years that I have been intently focused on certain areas of life, it was only a few years ago that I realized that a major part of my life was basically totally undeveloped and unexplored, ie, my spiritual life. As I have explored and developed this part of me, it has given me great personal pleasure and happiness, has been wonderful for my family and friends, and has given me a greater appreciation for what I do as a hand surgeon, a deeper caring for those that I treat, and a greater understanding for the need to reach beyond myself to serve others. When I speak of balance, I am referring to the interplay or intermeshing of various facets of life on a day-to-day basis. Aristotle thought of life as being an interplay of love, work, worship, and play. Dr L.D. Pankey (a British dentist, philosopher, and author) has written of life being a balance between career, education, family, emotions, church, nutrition, service, exercise, rest, and community.1Glazebrook P Happiness and fulfillment in dentistry.in: Quintessence Publishing Co, London1985: 18-19Google Scholar Thomas Moore, on the other hand, in his contemporary book Soul Mates, feels that “balance is a perfectionist's idea-never to be found in actual life.”2Moore T Soul mates. Harper Collins, New York1994Google Scholar Aristotle felt that balance was achievable and led to happiness. I agree with Aristotle that to be truly happy we need to balance the different areas of our life. I also agree with Moore, however, that this is a lifelong process. Today, I would like to talk to you about how balance in our lives effects our lives as physicians, men and women of society, and as the individual creation each of us is meant to be; how to know if you are out of balance; and if you are, what to do to change that situation. To begin our discussion of balance as it relates to our lives as physicians, I have been fortunate, as have most of you, to have spent my entire career studying and admiring the human hand. There is never a day that goes by that I do not marvel at the beauty and precision of this instrument. Are there any of us who do not feel blessed to be involved in the reconstruction of a rheumatoid hand: restoring metacarpophalangeal and proximal interphalangeal joint function with joint replacement or soft tissue reconstruction; to restore grasp by pollicizing an index finger, replanting a thumb, or performing a toe-to-hand transfer; to stabilize fractures, to repair lacerated tendons, or release contractures? We, of course, not only deal with the hand but with the person connected to that hand. It is about this latter portion of our work that Paul Brand so eloquently spoke when he said in 1991 at the Members and Fellows Luncheon: “A special source of happiness in hand surgery is the interaction between me as a person and the person of my patient. The hand, more than any other organ except the brain itself, is symbolic of the mind and soul of a person. It represents his life, his work, his strength and his love. One touch of a hand may mean more than a thousand words. The quality of the touch of my hand may mean more to a patient than the assurance of my voice or even the content of what I say. Touch is mutual. It is a seal of the oneness of the sick person and the healer. It is a statement that my thought and understanding, my sympathy and my faith have gone into the diagnosis and will now carry us forward together through the treatment. As a person, I stand behind my judgement, and with my hands, I demonstrate that I am there to serve the person whose life now is somewhat linked with mine.”3Brand P The pursuit of happiness.J Hand Surg. 1992; 17A: 595Google Scholar We are truly privileged to be in the position of caring for the human body, for as Sophocles wrote “numberless are the wonders of the world, but none—none more wondrous than the human body of man.”4Brand P Yancey P In His Image. Zondervan Publishing, Grand Rapids, MI1984Google Scholar As we interact with patients, we can simply be a base of knowledge or a compassionate, caring physician. Richard Selzer has written of the development of a compassionate physician that, “A surgeon does not slip from his mother's womb with compassion smeared upon him like the drippings of his birth. It is much later than it comes. No easy shaft of grace, this, but the cumulative murmurings of the numberless wounds he has dressed, the incisions he has made, all the sores and ulcers and cavities he has touched in order to heal. In the beginning it is barely audible, a whisper, as from many mouths. Slowly it gathers, rising from the streaming flesh until at last it is a pure calling.”5Selzer R Mortal lessons: notes on the art of surgery. Simon and Schuster, New York1976Google Scholar To become this type of physician, I believe one needs to have an inner presence of peace. To quote Dr John Najarian, past president of the American College of Surgeons, “The surgeon must have a soul, an inner unwavering commitment to the highest standards of responsibility and compassion,”3Brand P The pursuit of happiness.J Hand Surg. 1992; 17A: 595Google Scholar and Paul Brand writes, “When we have shared not only our knowledge and skill but part of ourselves with our patients, when we see something of hope and faith awaken in them, then something comes back to us. It is in the mutuality of medical care that we experience real joy.”3Brand P The pursuit of happiness.J Hand Surg. 1992; 17A: 595Google Scholar Horace Mann writes, “Doing nothing for others is the undoing of one's self. We must be purposely kind and generous or we miss the best part of existence. The heart that goes out of itself gets large and full of joy. This is the great secret of the inner life. We do ourselves the most good doing something for others.”6Swenson R Margin.in: Nav Press, Colorado Springs1992: 114Google Scholar This development of the inner self and the reaching out of a physician beyond his or herself to touch the inner need of the patient is our calling. To be the best at this that we can be, we need a balanced life! Turning to the world outside of the operating room and our office, we see a fast-paced, troubled society. British economist E.F. Schumacher has observed that the modern world finds itself “tumbling from crisis to crisis,” ie, a prison crisis, health care crisis, family morals crisis, adolescent/suicide crisis, savings and loan crisis, sexually transmitted disease crisis, an ethics crisis at every level of personal and public life.7Schumacher EF Small is beautiful: economies as if people mattered.in: Harper and Row, New York1973: 157Google Scholar Gerry Rifkin writes “each day we awaken to a world that appears more confused and disordered than the one we left the night before.”8Rifkin J Entropy: a new world view.in: Bantam, New York1980: 3Google Scholar There is overload everywhere today. Thirty thousand scientific journals exist in the world and there are 22 million books in the Library of Congress. Ninety-eight percent of Americans have more than one TV set and the average American watches 7 hours per day. We buy more books per capita than ever before, that is 45,000 new titles per year. Seventeen hundred newspapers are published daily worldwide. How can one find time to read a 2-inch Sunday paper? Our population is also on overload. Every time the world turns, there are 250,000 people added.6Swenson R Margin.in: Nav Press, Colorado Springs1992: 114Google Scholar Crowding is everywhere. Roadways are known as clogways. Our national flower is the cloverleaf. Rush hour is neither rush nor an hour very often anymore. It would appear that adding one more thing will not hurt but, if one is near the limit, then it will hurt and in fact, may break us. In this country, lawyers outnumber counselors 10 to 1, prisons are going up faster than day care centers, some divorce courts require metal detectors before former lovers can even face each other, churches in the South are being burned, and children are killing children.9Jones LB Jesus in blue jeans.in: Hyperion, New York1997: 6Google Scholar Everything seems to be changing exponentially these days, including information, the gross national product, the gross federal debt, national defense expenditures, bankruptcies, health care costs, etc. Society needs our involvement, I believe, as caring, compassionate men and women. We are some of the privileged few, having been blessed with above-average intelligence and a set of circumstances that led to our becoming members of the most noble profession ever in existence and as a result, having, for the most part, immense job satisfaction, personal happiness, and material wealth. I believe we have an obligation to return some of these blessings to society. As Paul wrote, “From those to whom much has been given, much is required.”10The NIV Study Bible. Zondervan, Grand Rapids1973: 1565Google Scholar Turning now to those who surround us, I believe our spouses, children, friends, and even enemies need us today as never before. David Elkind tells us that all individuals in today's society face, to a greater or lesser extent, three major stresses11Elkind D The hurried child: growing up too fast too soon.in: Addison-Wesley, Reading1981: 26Google Scholar:1.fear, as a result of the increased violence that is present in today's society2.financial insecurity, as the job market today is such that few remain in the same job long-term; and3.aloneness. There is great aloneness in today's society as a result of separation of cultures and generations and divorce. What about our relationships and marriages? Medical marriages can be challenging12Christie-Seely J Marriage and medicine: the physician as partner, parent and person.Can Fam Phys. 1986; 32: 360-368PubMed Google Scholar:1.Married physicians have a 10% to 20% higher divorce rate than the general population.2.Of physicians who stay married, over 50% (and their spouses) say they are unhappy.3.Statistics prove significantly increased incidence of drug abuse, alcoholism, depression, and thoughts or acts of suicide among physicians and spouses.4.Long hours do not appear to cause marital problems in medical marriages; instead, long hours are oftentimes reported to result from a physician's desire to “escape” the tensions of a marriage. We need to realize that marriage is occasionally blissful and occasionally mortifying, with a mixture of all other possibilities in between. Marriage is felt by Thomas Moore to be the intertwining of our souls.2Moore T Soul mates. Harper Collins, New York1994Google Scholar Likewise, a family is not a home on a quiet suburban street with mom and dad and two kids. This is the physical family. A family is the soul or the interconnectedness of the members of the physical family. Families should be sources of stories, warmth, and traditions. Each has its soul and the family needs to create time to explore these feelings without being judgmental to allow them to develop. Turning to our most precious gifts, our children, I believe they desperately need our love, our guidance, and, most important, our time. In 1991, a Center for Disease Control survey reported that 27% of high school students had seriously thought about attempting suicide.13Attempted suicide among high school students, United States, 1990.Morbid Mortal Wkly Rep. 1991; : 633PubMed Google Scholar Suicide is a problem among youth throughout the world, with the problem being most severe in the following nations14Borgman D When kumbaya is not enough.in: Hendrickson, Peabody, MA1997: 4-5Google Scholar: New Zealand, 15.7 per 100,000; Finland, 15.0 per 100,000; Canada, 13.5 per 100,000; Norway, 13.4 per 100,000; and United States, 11.1 per 100,000. The Federal government recently spent $25 million and learned that “teenagers who feel themselves loved by their parents are a lot less likely to get into trouble than teenagers who find themselves unloved.”15Ambrose J Teen study doesn't reveal any surprises.USA Today. 1997; (Scripps-Howard News Service)Google Scholar Are you surprised? For years I have heard it asked, “What do kids of physicians want to be when they grow up?” The answer: a patient. Alan Toffler writes in The Third Wave, “Often as second wave institutions crash about our heads, as crime mounts, as nuclear families fracture as once reliable bureaucracies splinter and malfunction, as health delivery systems crack and industrial economies wobble dangerously, we see only the decay and breakdown around us. Yet social decay is the compost bed of new civilization. One of the most important things we can give our kids is the sense that they live in a world being born, not a dying world.”16Toffler A The third wave.in: Bantam, New York1980: 350Google Scholar And if what I have given you so far is not enough reason to convince you of the need to have balance in your life, please consider that we ourselves are important. We are each individuals created to be something. To discover what this is, we need to be intimate with ourselves. Being a friend to yourself is the foundation for all relationships, for it embodies the recognition of your inner self, ie, your soul or God. Intimacy begins with ones' self. If you are not intimate with yourself, you can not be with friends, family, and patients. To illustrate these points, I would like to share with you excerpts from two personal letters to me:“As a practicing hand surgeon for the past 10+ years, I devoted way too much of my life to my profession. In an innocent manner, the serious nature of what we do makes us give as much effort as possible during the day. When we come home at night, it is then difficult to continue to give the emotional output that we have during the day. As a result, either a ‘don't rock the boat’ or a passive type of role is easy to lapse into once you are in the confines of your home and your relationship with your children and spouse. The emotional expenditure during the day makes it difficult to give the required amount of critical evaluation and daunting effort to your family that you gave to your patients during the day.”“I think, if I could do things over again in my life, I would have been a much better father, husband and person and a little less outstanding as a hand surgeon. I feel like I have given away too much to patients at the expense of my loved ones and most importantly, myself.” And another friend wrote:“Dear Andy—You and I have been close friends for many years. In the time you have known me, I have been president of the school board twice, have coached 16 soccer teams, have led Girl Scouts camping, have found time to ski and to fish with you and our other friends, and have found time to walk my girls to school nearly every day. I am a happy man. It was not always that way.”“I grew up financially privileged, married my college sweetheart, and we set out to recreate our parents' lives. We were 21 and wonderfully immature. I was good at what I did, a hard worker and very smart. Success was a given. By age 27 I was the youngest head of a regional office of a major national company. By the time I was in my early 30's, we were wealthy and I was a workaholic. My wife might have been calling out for help—I don't recall. But I do recall the day I had my heart attack. It wasn't a heart attack, it was an anxiety attack. What great irony, what great fortune! Our two children had scarlet fever and my wife was pregnant with #3. She called at the office, she was tired and scared and at her wit's end. She wanted help, sympathy, just a few minutes of my time. I was actually irritated. After the third call, I said, ‘for God's sake I'll come home if you can't handle it.’ Halfway home, I had to pull over. I was dizzy and had chest pain. By the time I got home I was sure I was dying. She took one look at me and called the ambulance—just after I collapsed. The next three years changed my life. Doctors, of course, found nothing wrong with me. It was all in my head. I can remember my first trip to the shrink. ‘Look—if it's all in my head, give me some damn pills and get me back to work. I haven't got time for this crap.’ He laughed and said that some day I would look back and think that this was the luckiest thing that had ever happened to me. He was, of course, completely right.The kids are in college now, my wife works full-time, and the walks are less frequent but we are always in each other's hearts and minds. People ask ‘What did this compromise cost? What did you have to give up in your career?’ They are missing the point. I gave up nothing. I gained everything. It is hard to explain my balanced life. It wasn't planned—it was a wonderful gift.” William Butler Yeats has said “The intellect of a man is forced to choose perfection of life or of work and if it takes the second, it must refuse the heavenly mansion raging in the dark.”17Lazear J Meditations for men who do too much.in: Simon and Schuster, New York1992: 91Google Scholar Have you chosen perfection of work over life? If so, do you realize that you may be missing the heavenly mansion raging in the dark, ie, a whole other side of you? As illustrated in Fig. 1, most reach a point where they are fatigued yet still have good productivity, although perhaps not normal.6Swenson R Margin.in: Nav Press, Colorado Springs1992: 114Google ScholarIf stress mounts while in this period of fatigue, productivity goes down and we become exhausted, perhaps even reaching a point of complete burnout. It is very important to recognize the symptoms of fatigue before exertion and burnout take place. The psychological signs and symptoms of fatigue and exhaustion are depression, withdrawal, mental fatigue, chronic anxiety, feeling that things are slipping out of control, negative thinking, etc. The physical signs of being fatigued and exhausted are stimulation of the cardiovascular system (ie, rapid pulse, palpitations) and gastrointestinal overactivity (ie, hyperacidity, ulcers, diarrhea), and tightening of muscles, especially of the head and neck. Abnormal behavior indicative of being fatigued or exhausted includes irritation with friends and colleagues, bossiness, outbursts of temper, withdrawal, detachment, change in sleep habits, change in eating patterns, change in sexual drive, etc.6Swenson R Margin.in: Nav Press, Colorado Springs1992: 114Google Scholar To learn what shape we are in as the result of the stresses in our lives, review the list in Table 1, adding the average mean score for each activity.18Holmes TH Rahe RH J Psychosom Res. 1967; : 11PubMed Google ScholarTable 1Life Stress ChartLife EventMean Value1. Death of a spouse1002. Divorce733. Marital separation654. Jail term635. Death of a close family member636. Personal injury or illness537. Marriage508. Fired at work479. Marital reconciliation4510. Retirement4511. Change in health of family member4412. Pregnancy4013. Sexual difficulties3914. Gain of a new family member3915. Business readjustment3916. Change in financial state3817. Death of a close friend3718. Change to a different line of work3619. Change in number of arguments with spouse3520. Mortgage over $140,0003121. Foreclosure of mortgage or loan3022. Change in responsibilities at work2923. Son or daughter leaving home2924. Trouble with in-laws2925. Outstanding personal achievement2826. Spouse begins or stops work2627. Begin or end school2628. Change in living conditions2529. Revision of personal habits2430. Trouble with boss2331. Change in work hours or conditions2032. Change in residence2033. Change in schools2034. Change in recreation1935. Change in church activities1936. Change in social activities1837. Mortgage or loan less than $10,0001738. Change in sleeping habits1639. Change in number of family get-togethers1540. Change in eating habits1541. Vacation1342. Christmas1243. Minor violations of the law11Reprinted from the Journal of Psychosomatic Research, vol 11, Holmes TH and Rahe RH, Copyright 1967, with permission from Elsevier Science.18Holmes TH Rahe RH J Psychosom Res. 1967; : 11PubMed Google Scholar Open table in a new tab Many of these changes should involve positive and not negative reactions. It is not the nature of the change, but the change itself that is important. Reprinted from the Journal of Psychosomatic Research, vol 11, Holmes TH and Rahe RH, Copyright 1967, with permission from Elsevier Science.18Holmes TH Rahe RH J Psychosom Res. 1967; : 11PubMed Google Scholar How many of us have not had, for instance, in the last year or two:Tabled 16. Personal injury or illness5311. Change in the health of a family member4415. Business readjustment3916. Change in financial state38These four add up to:174 Open table in a new tab Not to mention death, divorce, or marriage! If your score is 150 or lower, you are on pretty safe ground. If it is between 150 and 300, you have a 50–50 chance of a severe health problem in the next 2 years. If your score is over 300, your chances of a major health problem increase to 90%. The answer: Keep all facets of life in perspective. This is, of course, not easy! It is easy for many of us to recognize the lack of balance in our lives but so hard to change. We are ambitious, have huge stable egos, guard our feelings closely, tend to focus on single issues, are obsessed with perfection, and tend to set boundaries poorly. We have been put on a pedestal for such a long period of time that we actually develop what has been termed “the pedestal effect,” frequently seeing ourselves as “me, the doctor.”19Ogilvie B Stress in the life of the surgeon. Instructional Course Lecture. American Academy of Orthopedic Surgeons, Chicago1984Google Scholar If this has not set us up for enough problems, we are expected to be superhuman. We are expected to be experts not only on hand surgery, but on all matters from football to politics to automobiles. We are expected to not just be good, but to be flawless, always 100%. We can not be flawless, of course, but we try: if we are not, it may lead to permanent disfigurement or death of our patient. No matter how hard it may be for us to break out of the mold of “me the doctor,” we must for all the reasons I have presented. We must keep our lives as hand surgeons in perspective or balance with our lives as spouses, parents, and members of society. To illustrate this need for perspective, Shirley wrote to her dad, the busy hand surgeon,“I haven't written in a long time, so thought that I would write to catch you up. Freshman year at college is great! I hardly have time to study at all. In fact, I find I am so busy with all of the parties, that I find little time to study.I have stopped going to mass. I have met this really great guy—Maharishi Janro. He is helping me develop my mantra and discover my inner self. Yoga is great. Later this spring we will be married. I will be a level 5 wife. He has 50 or so wives, so I will be in the top 10%. Our child is due in September. I plan to use no more grass or heavy drugs the last trimester of my pregnancy as we want our child to be healthy. I take being a mother very seriously, as you can see. We are going to give our child up to a Pakistani commune as they need more children.Really, I have decided to drop out of school and will be moving to Alaska. A friend of the Maharishi's has a room over his gas station where I can stay in return for pumping gas from midnight to 6 a.m. I have given next semester's tuition—$11,000—to the Maharishi's commune that I spoke about in Pakistan.Got to go now. Write soon. Love Shirley. P.S. None of the above is true. I did fail chemistry, however, and wanted you to put that in perspective.” To establish or re-establish balance, we need to reclaim what Richard A. Swenson6Swenson R Margin.in: Nav Press, Colorado Springs1992: 114Google Scholar has termed “margin in our lives.” Dr Swenson speaks of a place that exists in all activities of life, which is between where we are and the maximum limit we are capable of in that particular area, ie, our “margin area” (Fig. 2).When we approach or exceed our limits (ie, exceed our margin) in one sphere of our life, it detracts from another. Most physicians operate near or over the limit in some areas and therefore operate in a negative balance in other areas (Fig. 3).Fig. 3When we are out of balance, as with overextension into our careers, other areas of life receive far less (and probably inadequate) attention (illustrated here as family and worship).View Large Image Figure ViewerDownload Hi-res image Download (PPT)We should all strive to smooth out our extremes and avoid approaching our limits wherever possible (Fig. 4).Fig. 4Ideally, we will excel in some areas, do less well in others, but still keep all areas of life in relative balance without exceeding our “margin.”View Large Image Figure ViewerDownload Hi-res image Download (PPT) To regain this margin and rebalance our lives, it is imperative that we not start by spending more time with our wives or attending more of our kids' athletic events or taking up a musical instrument. We must first give up or cut back on time-consuming activities in which we are presently involved. We only can do so much. To cut back or give up, we must learn one of the hardest words in the English language for many of us to say: No! Once you have freed up more time, you can begin the long and slow process of regaining balance or margin in your life. Here are some specific things that have been shown to help6Swenson R Margin.in: Nav Press, Colorado Springs1992: 114Google Scholar:•Generate good will•Practice gratitude•Confess and/or forgive•Set realistic expectations•Accept what cannot be changed•Avoid frustration•Avoid anger and the desire for revenge•Be in the moment—listen intently to your loved ones. (love is spelled T-I-M-E)•Set an example•Exercise (sweat to forget)•Laugh (internal jogging)•Play•Meditate•Pray•Learn to relax (behavioral aspirin) Finally, I list for you the five paradigm shifts that I feel each of us must achieve if we are to work toward a more balanced and rewarding life:1.Accept the finality of the 24-hour day. Before adding more to your life, give something up. Learn to say NO! As part of this, accept and respect the boundaries of others, ie, their no's.2.Whatever you do in life, do it with passion! As Mother Theresa said, “The test of your life is not how much you do, but the passion with which you do it.”20Mother Theresa The simple path. Ballantine Books, New York1995Google Scholar3.Control your own lives. If I am I because you make me me and you are you because I make you you, then I am not I and you are not you. But if I am I because I make me me and you are you because you make you you, then you are you and I am I.21Woodman M The stillness should be the dancing. Texas A&M University Press, College Station, TX1994Google Scholar4.Set your boundaries. As Henry Nouwen has so eloquently stated, “When we have sold our identity to the judges of this world, we are bound to become restless because of a need for affirmation and praise. When our actions have become more an expression of fear than of inner freedom, we easily become the prisoners of our self-created illusion.”22Nouwen HJ Out of solitude.in: Ave Maria Press, Notre Dame, IN1974: 20Google Scholar5.Develop or strengthen your inner self or, if you will, faith in God. This will give you the strength and foundation from which to make some of the difficult choices we will need to make to achieve or to live a more balanced life. We owe it to our loved ones, our patients, society, and ourselves to be the best we can be, to be in balance.