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Physician heal thyself

2002; Elsevier BV; Volume: 187; Issue: 2 Linguagem: Inglês

10.1067/mob.2002.125702

1097-6868

Murray A. Freedman,

Ethics in medical practice

It is a great privilege and honor to serve as the president of this prestigious organization. I have great respect for its members, many of whom are leaders in the field of obstetrics and gynecology, not only nationally but also internationally. It is with great humility that I accept this challenge to present a presidential address. I take considerable comfort in knowing that we all have something significant in common: we all seek happiness. In fact, this goal is shared by all of the almost 6.5 billion humans on this planet. This quest for happiness, however, is a uniquely human characteristic. Dogs do not worry about happiness or improving their lifestyle; they occupy their time thinking about food and the avoidance of discomfort. The same can be said of essentially all animals, except humans. We are clearly the brightest species on earth, and, because of that, we are at the head of the animal kingdom. Despite our being at the top of this hierarchy, we are born into total disorientation and must literally learn everything, including happiness. The sad fact is that, as a group, today's physicians are not “happy campers.” Considering the fact that a growing number of physicians proffer that they would choose another vocation if they had it to do over again,1Sullivan P Buske L Results from CMA's huge 1998 physician survey point to a dispirited profession.Can Med Assoc J. 1998; 159: 525-528Google Scholar the problem seems to be getting steadily worse. Although the suicide rate among physicians was previously thought to be higher than that of the general population, more recent data suggest that it is only female physicians who are at greater risk.2Silverman MM Physicians and suicide.in: The handbook of physician health. : American Medical Association, Chicago2000: 95-117Google Scholar There are similar data emerging that drug abuse is no more prevalent among physicians than other comparable socioeconomic groups or professionals,3Dilts SJ Gendel MH Substance use disorders.in: The handbook of physician health. : American Medical Association, Chicago2000: 118-137Google Scholar, 4Avery DM Daniel WD McCormick MB The impaired physician.Primary Care Update Obstetricians/Gynecologists. 2000; 7: 154-160Crossref PubMed Scopus (6) Google Scholar but psychiatric illness, especially depression, is thought to be more common.5Hendrie HC Clair DK Brittain HM Fadul PE A study of anxiety/depressive symptoms of medical students, house staff, and their spouse/partners.J Nerv Ment Dis. 1990; 178: 204-207Crossref PubMed Scopus (51) Google Scholar Much of this discussion attributes responsibility for this trend to the predisposition of the individuals who enter the medical profession. Contrary to popular belief, the divorce rate among physicians is actually lower than in other comparable socioeconomic and professional groups.6Doherty WJ Burge SK Divorce among physicians.JAMA. 1989; 261: 2374-2377Crossref PubMed Scopus (32) Google Scholar, 7Rollman BL Mead LA Wang N Klag MJ Medical specialty and the incidence of divorce.N Engl J Med. 1997; 336: 800-803Crossref PubMed Scopus (62) Google Scholar Among the many reasons for the lower divorce rate are the very characteristics that most physicians embody: a kind, caring attitude; desire not to hurt the family; concern about their professional reputation; and disdain for admitting failure—to mention only a few. Ministers and politicians are the only groups more cognizant of their professional reputations. Physicians' spouses are equally reluctant to seek divorce because of the inevitable loss of income and “social status” and a similar sense of obligation to keep the family together. What has really accelerated the discomfiture of physicians is the “managed care” environment, a system dominated and essentially dictated by third-party reimbursement (ie, insurance companies). In their recent book about medical marriages, The Resilient Physician, 8Sotile WM Sotile MO The resilient physician.in: : American Medical Association, Chicago2002: 3-30Google Scholar psychologist Dr Wayne Sotile and his wife point out that physicians function well under “high-stress, high-control” situations, but when they are in “high stress, low control” situations, they begin to decompensate (Fig 1).It is not so much the stress that devastates physician morale; it is the loss of control. Physician distress and tribulation are certainly not new. The first law of medicine, non primum nocere or “first do no harm,” is known to all in the medical profession. The second but less-known law of medicine, Docktor auxiliore sui or “physician heal thyself,” also has its roots in antiquity. This ever-present susceptibility among those whom society considers so strong is rather interesting, considering that there is evidence that physician vulnerability to stress has more to do with the personality traits that are possessed by those who enter the medical profession than the practice of medicine per se.2Silverman MM Physicians and suicide.in: The handbook of physician health. : American Medical Association, Chicago2000: 95-117Google Scholar, 8Sotile WM Sotile MO The resilient physician.in: : American Medical Association, Chicago2002: 3-30Google Scholar, 9McCranie EW Brandsma JM Personality antecedents of burnout among middle-aged physicians.Behav Med. 1988; Spring: 30-36Crossref Scopus (89) Google Scholar Although it was once thought that certain specialists, such as anesthesiologists and psychiatrists, were more susceptible to suicide and substance abuse, it is now recognized that such differences between medical specialties are exaggerated. The cause lies more with the personality and emotional makeup of the individual than with the specialty that is chosen. For instance, it is more the personality of physicians who choose psychiatry than it is the practice of psychiatry that explains their inordinately high divorce rate.7Rollman BL Mead LA Wang N Klag MJ Medical specialty and the incidence of divorce.N Engl J Med. 1997; 336: 800-803Crossref PubMed Scopus (62) Google Scholar Getting back to our common denominator (happiness), who among us would not like to be happier? As Prager points out in his book, Happiness is a Serious Problem, 10Prager D Happiness is a serious problem. : Harper Collins, New York1998Google Scholar the only totally happy people in the world are those who we really do not know well. Sadly enough, even human nature works against us to some degree. It is normal to be a little greedy, and we all tend to be a little prone to excesses: “never too thin,” “never too rich,” “never enough time.” Society tends to focus on negatives, the media being a prime example. This negativity has its origin in infancy. What is the most common word a 2-year-old child says? “No!” And why do you suppose the word no is a 2-year-old child's favorite word? Because negativity is what he hears the most: “Don't do that,” “Put that down,” “No, no, no …” The average child hears “no” 25 to 30 times a day; when you do the math, that works out to be almost 140,000 times before they leave home for college. Characteristically, people are scolded for negatives and rarely recognized for normal, positive behavior. Noted motivator and author, Ken Blanchard, author of The One Minute Manager, 10Prager D Happiness is a serious problem. : Harper Collins, New York1998Google Scholar aptly suggests that we should find people doing things “right” and praise them (motivation) rather than always looking for and condemning people who are doing wrong. Prager points out that humans are not typically “happy campers” by nature.10Prager D Happiness is a serious problem. : Harper Collins, New York1998Google Scholar He correctly describes how young children must be taught to watch games, play with toys, and be entertained. Being happy is simply not an inherently natural event. Children learn most of their behavioral characteristics from their parents, and because of their rather obsessive-compulsive personality traits, physicians sometimes take parenting to the next level. For instance, a child makes a score of 97 on a test and is “encouraged” with the observation, “Study just a little bit harder, and you will make 100.” Three As and one B on a report card is met with, “Look at that! You almost made 4 As.” On the other hand, all good coaches know that the way to enhance performance is by positive feedback; disdain and scorn tend to discourage participants. Winners always find a way to incorporate a positive spin. Vince Lombardy once stated that he had “Never lost a game…. Time simply ran out.” Thomas Edison did not “fail” in his first 1100+ tries at harnessing electricity for light; he stated that he had found 1100+ ways not to illuminate the light bulb. Theodore Roosevelt said, in a speech at the Hamilton Club in Chicago (April 10, 1899), “Far better it is to dare mighty things, to win glorious triumphs, even though checkered by failure, than to take rank with those poor spirits who neither enjoy much nor suffer much, because they live in the gray twilight that knows not victory nor defeat.” I am reminded that the translation of the Chinese character for the word crisis represents both danger and opportunity (Fig 2).You cannot steal second base with one foot still on first! The fear of failure has been the ruination of many good athletes and businessmen alike, and it is only through repetitive positive reinforcement that failures are transformed simply into outcomes. Henry Ford is credited with having expressed this concept succinctly: “If you think you can, or that you cannot … you are correct!” Fear of failure and negativity can be very detrimental to self-esteem, as well as actual achievement. Prager10Prager D Happiness is a serious problem. : Harper Collins, New York1998Google Scholar also accurately describes how we tend to focus on minor imperfections and frailties (the “missing tile” syndrome) and miss the big picture. Whenever we look at an otherwise attractive, decorative ceiling, all we see is the missing tile; there are hundreds of tiles, yet we always focus on that single area! Our home has a large, comfortable living room, and it has incredibly warm and friendly features, but the minute I walk into that room the first thing I always notice is a recurrent crack in one seam of the otherwise stunning vaulted ceiling. A balding man walks into a crowded room and immediately scouts out the receding hairlines. The Venuses of the world always focus on that 1 cm of cellulite that, for them, is their most obvious characteristic. We should be focusing on what is there and good rather than what is missing or wrong:‘Twixt the optimist and pessimistThe difference is droll;The optimist sees the doughnut,But the pessimist sees the hole.— W. McLandburgh (1915) Why is an obsessive-compulsive personality trait so characteristic of physicians and other top professionals? The obvious answer is selection bias because it requires foregoing considerable pleasure and postponing fun just to get into graduate schools, especially competitive professional schools. Medicine is particularly unique in this predisposition because this quirky personality trait is actually nurtured by the process of becoming a doctor so that, by the time you finish the rigors of training, the obsessive-compulsive characteristic is an indelible part of who you are. Adjectives such as dedicated, conscientious, committed, and even sacrificial characterize medical school admission criteria rather than such characteristics as warm, gentle, friendly, agreeable, and adaptable. Furthermore, medical training encourages an attitude of postponement: “Next year, after I don't have anatomy, biochemistry and microbiology, I'll relax a little more.” “Next year, when I'm not on call every third night and working up patients all night, I can enjoy the family and the weekend.” “Next year, when I am not the ‘scut' doctor, I'll make out the schedule, and I will be off on some holidays.” “Next year when I am the Chief Resident, I won't have be in clinic so late every day.” “Next year when I am not the junior partner, we can take that vacation we have always wanted.” “Next year when we get a new partner, I can start going to the beach with you on weekends.” And finally, “Next year …,” and you die. The worst part about this scenario is that the longer it goes on, the more adept we become at explaining our postponements. It is purely rationalization. Amazingly, physician divorce rates are not inordinately high.6Doherty WJ Burge SK Divorce among physicians.JAMA. 1989; 261: 2374-2377Crossref PubMed Scopus (32) Google Scholar, 7Rollman BL Mead LA Wang N Klag MJ Medical specialty and the incidence of divorce.N Engl J Med. 1997; 336: 800-803Crossref PubMed Scopus (62) Google Scholar The very last part of a physician's life to unravel is typically the medical practice, but family life often gets compromised or sacrificed early in life's daily shuffle. This competition or dilemma of the family versus medicine actually accelerates and worsens the obsessive-compulsive disorder because, when that part of our lives becomes stressful, unpleasant, or frustrating, we then tend to gravitate to the office where we receive rewards and where we unquestionably do best. When criticism, scrutiny, or lack of appreciation dominates the home environment, a vicious cycle ensues; physicians naturally seek the praise and recognition that now emanates from the work place, not home. As humans, we all tend to gravitate toward a happy, pleasant environment, but we would be wise to remember that this migration may apply to other family members as well. We all have a moral obligation to our significant others to be happy; no one wants to live with a perennial grump. We owe it to our spouse and family members to find a balance between work and home so that coming home is pleasant for all involved. There is a distinct difference between the dedicated, hard worker and the workaholic: one is typically happy; the other is very rarely at peace. Distinguishing features of the called professional and the typically driven one are contrasted in the Table.Tabled 1Table. Characteristics of a “called” versus “driven” physicianCalledDriven50-Hour work week100-Hour work weekDedicatedWorkaholicContentIrritableIdentifying purposeReaching goalsBeing and becomingHaving and gettingSelf-esteemEgo Open table in a new tab The workaholic is pathologically obsessive-compulsive, constantly under pressure, in a hurry, always behind: his work is never done! There is rarely time for the family because “sacrifices” always take priority: “on call,” a sick patient, a critical meeting, the emergency department, a consult. “But, next time …” There is a genuine feeling of being compelled to do these things. On the other hand, the dedicated physician is typically efficient, is busy but works reasonable hours and at a comfortable pace, is at ease with his work, and most important, enjoys work. He is calm and relaxed because he does not have the constant fear that someone else might do the job better, beat him to the punch, replace him, or criticize him. The workaholic feels driven and does not enjoy his life; he is driven by tension. This entire conundrum has arisen because goals have replaced purpose. The saddest part of the scenario is that, once a goal is accomplished, the bar is simply raised, and the cycle begins again. This imbroglio causes the workaholic to become obsessed with “getting” and “having” rather than “being” and “becoming.” There is never enough. The obsessive-compulsive individual wants personal ownership of everything, which usually coincides with a certain fear of losing everything. On the other hand, the dedicated professional simply enjoys “shepherding” the gifts without the fear of them being stolen or lost. The sad result of the workaholic's incessant search for nirvana is that the work “is never done” and that happiness is inevitably elusive. Happiness comes from purpose, which is internal, rather than goals, titles, and awards, which are external. The former has to do with self-esteem, the latter with ego. Another impediment to happiness is the failure to develop good self-esteem while allowing ego to flourish. Self-esteem is what you really think of yourself; ego is your perception of what other people think of you. Two notable celebrities who exemplify tremendous ego but poor self-esteem are Marilyn Monroe, who despite garnering love and adoration from an admiring public purportedly committed suicide, and Dion Sanders, who attempted suicide despite his tremendous athletic ability, incredible sports notoriety, and Super Bowl victory. Both of these individuals are victims of enormous ego but a pitiful lack of self-esteem. Ego is dependent on other people and what they think of you, although self-esteem has nothing to do with anyone else. Your self-esteem is totally dependent on you and no one else. There is a line in Shakespeare's Hamlet that defines the concept beautifully: “This above all: to thine own self be true, and it must follow as the night the day, thou canst not then be false to any man.” One of the keys to good self-esteem is the elimination of ego. Self-respect is not dependent on outside input. This concept begins to get to the true crux of happiness in that genuine happiness is internal, not external. Happiness is an attitude, not an event. No single event will make you happy, but how often do we each think, “If I just had a higher salary…” or “If I had that position …” or “If my spouse just had …” or “When I finish this …!” It is very much like the missing tile syndrome. Integrity is an integral part of this concept. With integrity, the “right” decision is already in place before the situation even arises. That is, morality is totally independent of emotions and conditions. People with good integrity embody impeccable honesty. One of my proudest moments as a parent occurred when my daughter was about 12 years old and competing in an important state tennis championship. She chose not to call a very close ball “out,” although she felt sure that it was out. Her reasoning was that she was not absolutely 100% convinced that it did not touch the back edge of the line. She lost that critical point and the match, and she and her coach were extremely disappointed. He made the comment that she had every right to have called the ball out, which would have changed the outcome of the match, although she could not be absolutely positive of the call. He parenthetically added, “Besides, it was so close, no one would have ever known the difference.” My daughter's indignant response could not have been more perfect: “I would have!” For people with integrity, the decision does not depend on the circumstance; the proper choice has been made well before and independent of any situation that arises. It is not a question of who is right but rather what is right. Integrity is a prerequisite for good self-esteem and an essential part of it. Most psychologists and philosophers agree that happiness in life is 90% perception and only about 10% reality. This is especially true for sentiment, particularly love and affection, and the primary reason for this is our incredible intelligence. The greatest pleasure that is associated with a new fancy car, boat, or a child's special Christmas gift is the day before it actually became a reality. Infatuation is a perfect example of this phenomenon. A more thorough discussion of psychology is beyond the purview of this address, but it is well recognized that happiness is not dependent on tangible, material things. Many people appear to have “everything,” yet nothing seems to please them; many others with so little are ecstatic. As internationally known inspirational speaker Zig Ziglar said, “Your altitude in life is more dependent on your attitude than it is your aptitude” (1992). Because a large part of happiness emanates from feeling important and being needed as a person, it is quite normal for people to be egocentric. After all, you are undeniably the center of your own little world. It is entirely normal when you look at a group photograph to look first for yourself. Ego and egotism, on the other hand, are detrimental qualities because they are dependent on others' opinions of you rather than your own. Self-esteem and integrity are both undeniably internal events. That having been said, humans learn to be sentient beings, and this is dependent on other people. This paradox is explainable. Nurtured infants learn very early on the pleasure of attention and being loved. This early love and positive feedback contribute significantly to humans becoming the affectionate creatures we are. Premature animals who are coddled open their eyes earlier than ignored littermates; monkeys that are shown affection move toward the front of their cage for social interaction; monkeys that are ignored are reclusive and withdraw to the rear of the cage. Receiving love and appreciation is paramount to development, and considerable attention and positive feedback are critical to the young of all species. Humans are quite unique, though, primarily because of our intelligence. We learn early on how to win affection. Although being loved is essential, it is prudent to point out that the truly greatest pleasure in life is in loving, not being loved. Love is not truly love until it is given away. It was actually St Francis of Assisi in 1225 who wrote: O divine Master, grant that I may not so much seek to be consoled as to console; to be understood as to understand; to be loved as to love. For it is in giving that we receive; it is in pardoning that we are pardoned; and it is in dying that we are born to eternal life. All parents and grandparents know the “pure” pleasure of giving. A similar, simple example of unilateral giving is seen in an act as mundane as petting your dog. The animal loves it; you enjoy it, and the more the animal gets excited, the more pleasure you derive from doing it. This is because the dog's affection is unconditional: he will not take you to Europe, buy you a fur coat, or take out the trash, and he expects nothing in return for the affection. This unconditional love is pure, unadulterated giving. Perhaps this is why dog is man's best friend: love without conditions. (Is it purely serendipity that God spelled backwards is dog?) The absence of prerequisites and stipulations is what distinguishes agape from philos and eros; agape is totally unselfish and unconditional. The ancient sages were absolutely right: “Tis better to give than receive.” This represents just one more example of divine inspiration, but somehow, we have forgotten this over the ages. A quote from Spanish philosopher and writer George Santayana is apropos: “Those who cannot remember the past are condemned to repeat it.” Affection represents “learned behavior.” Neglected children do not develop the capacity for warmth and tenderness without being nurtured; humans learn to be sentient beings. The good news is that even those who do not initially develop this “loving” attitude because of a lack of attention or neglect are not condemned to a life without it. They can still learn. The touching story of “Beauty and the Beast” is but one parable that illustrates such a reformation. It is estimated that the brightest of humans actually uses <10% of the brain; ergo, we all have this incredible potential to learn. Developing a positive attitude requires considerable practice. It is a bit trite to talk about the glass being half full or half empty, but the optimist and the pessimist do look at the same situation in opposite ways. Renowned contemporary motivators, from the Dalai Lama to Wayne Dwyer, PhD, to Deepak Chopra, MD, all agree: you become what you think about. “I am sick and tired of this, and I am sick and tired of that.” “I am sick of …” becomes a self-fulfilling prophecy in that you actually do become sick and tired. As mentioned previously, perception is far more powerful than reality. This morning represented a perfect example for me personally. On awakening, I was angry because I had only slept for 6 hours; I did not have brewed coffee immediately available, and I had to hurry because I was running late. I needed to review my notes for this address, I had to dress quietly in the dark, and I had to keep the bathroom neat (because my wife is with me). I had not even gotten to the bathroom, and 20 seconds into the day I was already in a bad mood. Then I reconsidered: 6 hours of uninterrupted sleep is actually very adequate, and I would have my instant coffee within 30 seconds. I am president of this wonderful organization, and I will have the privilege of giving this address at noon. Furthermore, in contrast to most trips, my wife and family are accompanying me this time, what a fantastic day! In fact, this may be the best day of my life. Intellectually, I already knew this would be the greatest day of my life. Yesterday is but a memory, and tomorrow is but a hope. Today is the day, and is it beautiful! The same 20 seconds, the same person, the same day! Yes, it does take practice, constantly. Along with the ministry, medicine is one of life's most rewarding vocations. The practice of medicine is testimony that rewards really are equal to service rendered. The monetary remuneration has certainly been severely compromised, but the personal satisfaction and gratification gleaned from helping people remains unimpaired. This includes not only life-saving therapeutic endeavors but also conventional preventive care. Essentially, all physicians would readily agree that the greatest reward from the practice of medicine (one that far exceeds any associated monetary retribution) is the inner personal pleasure of healing the sick. “Doctor, you saved my life” still conveys the same immeasurable, intrinsic value. All physicians dearly cherish those fantastic but essentially unheralded triumphs, such as the obstetrician's resuscitation of a compromised newborn infant who otherwise would not have survived. Nothing can ever begin to compare to this feeling of accomplishment and pride. It is almost never accompanied by an audience, fanfare, visible recognition, and sometimes not even gratitude; it does not need to be. You know! Can any other profession grant such fantastic rewards? Priceless! Make no mistake about it, though; we should not be Pollyannas. Managed care is a threat to the medical profession and to the care our patients deserve, and we should continue striving to improve both. We would be well served to reread the Hippocratic Oath periodicly. Remuneration should not have an impact on therapy, but it is inevitable that unfair reimbursement will ultimately take its toll on the quality of care available in this country. Equally ominous, however, is what managed care is doing to the spirit of the practicing physician. Who will be left to take care of you and me in the future? Yes, we have an obligation to preserve the greatest health care system in the world, but we must also remember the equally compelling moral obligation to be happy while we are doing it. We owe it to our family, friends, and colleagues; these are the very people who deserve our happiness most. We can ill-afford to take our loved ones for granted. You and you alone determine your attitude. The guy in the car behind you who rudely blows his horn can be extremely irritating, but only if you allow it to bother you. He may be angry, irascible, and having a terrible day, but his mood does not have to become your problem, too. Do not allow him or his ire to influence you one iota. You are in control, and although it may take lots of practice, your attitude will determine your happiness. You really do become what you think. Happiness is an attitude, not an event. We need to examine our lives and define our mission, our purpose. We should not allow ourselves to be lured astray by life's meaningless titles, goals, and trivialities. We can learn to be happy; but remember, it will require considerable practice. We come into this world naked, and we will exit naked; all of that “noise” in between is really irrelevant. There is no dress rehearsal for life; this is it; this is “next year.” We need to enjoy the journey, not merely focus on arriving at the destination. Each of us is in control of our own destiny, but we would be wise to remember Pogo's admonition: “We have met the enemy, and they is us!”