Portal de Periódicos da CAPES

Pro

2004; Elsevier BV; Volume: 77; Issue: 4 Linguagem: Inglês

10.1016/s0003-4975(03)01443-7

1552-6259

Jamie Dickey, Ross M. Ungerleider,

Healthcare Systems and Technology

Steve White was on vacation with his wife. They had left the cold, windblown climate of their upper Midwest town very early that morning. Steve always told his wife that thoracic surgeons do not mind getting up early. She always preferred to keep the blinds drawn so as not to awaken from the first light of dawn. However, when they traveled together he invariably booked them on the first flight out of town, thus requiring them both to wake up shortly after she, a night person, would ordinarily be going to bed. Steve had begun his practice 18 months ago after 9 grueling years of training. He and Meg met, courted, married, and had 2 children during his residency. Although Meg quit her job after their son was born, she remained occupied with raising the family, but Steve continued to spend time at the hospital. If they could just make it through Steve's residency, his nights on call, and the constant pressures to do things right for his attendings, then life would get better. They would find a job in a town where they could raise their children and have a more normal family lifestyle. This was more than a year ago and as far as Meg could tell, there had not been much of a change. Steve now toiled for his partners, in order to uphold his share of the responsibility. He kept reminding his wife that life would improve once he was more established with his partners and they knew he was not a slacker. He always seemed to say “yes” to work, which according to her perspective meant he was saying “no” to her and the children. Just getting Steve to agree to this vacation was huge. He was, of course, delayed at the hospital the night before, so Meg had to go to the dry cleaners and the bank, which were the errands that he was supposed to handle on his way home. Ironically, she planned on that occurring, because Steve was always detained. For this vacation, Steve brought his computer, his last 6 months of issues of The Annals of Thoracic Surgery, his long-range pager, and his cell phone. He had instructed his partners to call if things got out of hand, because he could come back. This was, after all, just a vacation, and he could abort it if necessary. He felt relief being able to tell that to his partners, which indicated his dedication to helping make the practice work. He knew that he really would not want to come back, yet he was curious why he felt ambivalent about leaving. He was also bringing his golf clubs, a swimsuit, and a candle (a surprise for Meg on their first night together in their Caribbean hotel). It was the candle he bought for their first date, and every now and then he represented it to her as an offering of his romanticism. This was Steve's first vacation since he had joined the practice. His role models in residency training at the university rarely seemed to take vacation time. In fact, he recalled how often they would make comments around the operating table that ridiculed the banality of being with the family. Steve, himself, had been asked to page a few of his professors away from their families on weekends, so that they could have an excuse to leave some onerous function. It seemed to Steve that being a surgeon provided some of his mentors with a socially acceptable excuse for abandoning their families. This bothered him a bit, but over the years of training he noticed how comfortable he felt around the hospital and especially in the operating room. He got most of what he wanted, when he wanted it. And he was treated with such deference. When he got home, he did not have the same clout. Meg treated him like a regular person, and it just was not as much fun. During his first year of practice he worked as though he were still a resident. He covered the practice whenever he was needed. He was, after all, the junior partner, and he had dues to pay. The flight with Meg was a reconnection with their hopes. For the first time that he could remember in months, they had fun together. They flew first class. They drank wine and talked about all the things they could do together without the kids. When they got off the plane it was sticky warm. After hours of being confined to a seat in an airplane, the tropical air relaxed them like it was a drug. The hotel had a driver waiting for them. Steve did not have to do anything, and it felt good. He was thinking about how much Meg would love the candle. It was when they were checking into the hotel that he got the message. “Dr and Mrs White, welcome to our beautiful island paradise. We will do everything we can to make your stay wonderful. I noticed that there is a message for you. Let me retrieve it. It will only take a moment.” Steve looked at Meg, “Do you think your mother is having a problem with Sarah? She was not so happy about our leaving?” He felt some of his senses tightening. It was hard to relax after being found. He was used to bracing himself into this mode of getting ready to deal with a problem; he did it every time his pager went off. “I do not think so. Mom knew how much I was looking forward to this. I can not imagine her bothering us unless it was an emergency.” They shared an apprehensive look. The manager handed Steve an envelope addressed to Dr Steven White. He opened it and read it: “Please call ASAP.” The note was from his senior partner, Preston, and it included his cell phone number. Now all of the connection between Steve and Meg dissipated. He reached into his pocket for his cell phone. Damn! No service on the island. Steve needed a phone. He found one in the lobby. Meg went to check into their room. It was the mayor. He was unstable and needing urgent surgery for acute aortic insufficiency from endocarditis. Steve's partner was going to perform the operation, but he wanted Steve's help. Preston thought the mayor would benefit from a Ross procedure, an operation that Steve had acquired a lot of experience with when he was in his residency. Preston was still learning the Ross procedure, and with Steve's help, he was getting pretty good at it. However, he did not want to do this one alone, because this was the mayor for God's sake! This would be hugely important to their practice. Television and the Press would be following this story closely. Everything had to go well. He hated to ask, but this was so important. Besides, Steve had said he could come back if things got out of hand. Meg could enjoy the island for a few days and Steve could be back the day after surgery. “Sure,” Steve said numbly. It was not what he meant, not what he wanted, but it was what he said. “I will look into the flights back. I need to tell Meg. I will call you when I have some information.” “Thanks, Steve. You have been a wonderful partner. This is what we have to do sometimes.” “Right,” thought Steve, as he placed the receiver in the cradle and tried to refocus on where Meg might be. He reached into his pocket for his card key for bungalow 15. Life wasn't fair! Steve walked slowly, reflectively along the beautifully manicured, fragrant path that led toward bungalows 11 to 24. When he got to bungalow 15, he was not finished thinking. He was not sure what to say to Meg. He was not really sure what to say to himself. If it were not for Meg being here with him, he would have no problem with going back. In fact, he was aware that there was a part of him that felt he belonged back in the hospital. He was very comfortable with that part. It was like being on a well-traveled path. This is what you have to do in this line of work. It was the dutiful thing. A health professional is supposed to put the lives of others first, right? What about Meg's life? What about his life? Throughout residency, he tried so hard to please others. There were so many demands from others. He learned how to accommodate and this became his well-traveled path; it was why there was a strong force compelling him to return to work. He knew that feeling of self-sacrifice and delayed gratification; it had become a way of life. He could slide into it the way an alcoholic decides to have another drink. Had work become an addiction? How could he deny the importance of helping Preston do a Ross procedure on the mayor? And it would be so good for the practice. The media coverage alone would bring them countless patients. Preston would be so appreciative. Meg would, once again, understand. She would understand. She would be disappointed, but she would understand. How many times could he disappoint Meg? She was incredible, but she was human. Listen to her in there singing. She is so happy to be here. I will not be asking her to leave. I will be back in a few days after I do the professional, dutiful thing. I will be proud of myself. Steve sacrifices himself again. You can count on Steve. Damn—a bungalow, candlelight, and Meg! Can I choose myself and still be a professional? I do not want to go back. I want to stay here. I mean, I could go back, and I know Preston needs me, and it would be so good for our practice. It is just a couple of days. It is not like I am canceling the whole vacation, and if I do not go, I will feel so guilty. I guess I do not really get to choose myself unless no one else needs me. Meg will understand. I can suck it up. The air feels so good here. I want to take a walk on the beach and hold Meg's hand, come back to the bungalow, and relight our candle. We will leave Steve here at the threshold of his bungalow, struggling with a no-win dilemma. In some form, we have all dealt with this dilemma. We have been “enculturated” to put our profession first before ourselves, our family, our being human. During training, thoracic surgeons are never taught balance. Can you be professional as a dutiful thoracic surgeon and be balanced? How does Steve make the correct decision? In fact, is there a correct decision? What is required of Steve is to create a life of balance and fluid movement among three important conceptual aspects in his personal system. For example, he must learn the importance of valuing and respecting himself, his relationship with Meg (family, or others), and his medical practice (partners, patients, and media, which are the context of his job). To ignore or consistently choose one system ingredient (self, other, or context) over another will create an unbalanced and rigid lifestyle, putting Steve, his wife, and his medical practice in jeopardy. It may be possible for one aspect in Steve's system to grow and thrive temporarily, if it is consistently being chosen over other aspects in the system; however, even the chosen aspect will eventually suffer if one or both of the other aspects is destroyed. What is the price to us of not having balance? Steve makes the well-traveled decision and returns to work. Once again, Meg understands. The statistics are grim. If Steve continues to make the decision that work comes first before his needs, including his relationship with Meg and their children, he may end up chronically depressed or with a substance abuse problem, which has been recorded as high as 8% to 12% among physicians, or he may even end up with both problems. With a little additional stress, such as his health or finances, he could become suicidal. The risk of suicide is higher in physicians than in the nonmedical population. Each year it would take the equivalent of one to two average-size graduating classes of medical school to replace the physicians who commit suicide. The risk seems especially high for those who are driven, ambitious, individualistic, and compulsive. The previous description represents the profile of a thoracic surgeon [1Gundersen L. Physician Burnout.Ann Int Med. 2001; 135: 145-148Crossref PubMed Scopus (197) Google Scholar, 2Miller M.N. McGowen K.R. The painful truth. Physicians are not invincible.South Med J. 2000; 93: 966-974PubMed Google Scholar]. Suicide is an extreme. More likely, the physician may end up divorced. That is not what Steve set out for when he bought that candle for his first date with Meg. It is a well-published fact that the divorce rate for physicians is 63% versus the national norm of 43%. The risk is highest for psychiatrists and surgeons, and this is especially true for female surgeons. More frightening is the fact that those couples who do stay married report a higher incidence of being unhappy [1Gundersen L. Physician Burnout.Ann Int Med. 2001; 135: 145-148Crossref PubMed Scopus (197) Google Scholar, 2Miller M.N. McGowen K.R. The painful truth. Physicians are not invincible.South Med J. 2000; 93: 966-974PubMed Google Scholar]. During the training years, thoracic surgeons become masters at delayed gratification. Residents spend years coping with the high level of demand required of them in surgery, often harboring the expectation that later they will be rewarded with a happier, more balanced life [2Miller M.N. McGowen K.R. The painful truth. Physicians are not invincible.South Med J. 2000; 93: 966-974PubMed Google Scholar]. Perhaps Steve makes the decision that Meg will not understand and that if his marriage is to survive, he just can not return to work. After awhile, making decisions to placate Meg, Steve begins to resent her. She is holding him back. She used to understand and support him. If it were not for her demands, he would be happy. How did this happen—this gradual slide into unhappiness? He just can not keep everybody happy anymore. When did this become his responsibility? What about his happiness? Why is life so hard? What would Steve do for Steve if there were only Steve to satisfy? The unsettling reality is he has no idea. He has spent so long in a culture that has taught him to take care of others, often demanded him to take care of others, to the point that he has no idea of how to take care of himself. He has derived his happiness from serving the needs and demands of others. When his pager goes off, he has ambivalence. He hates to be bothered, but at least it creates something important and meaningful and he knows he has to respond. This is why he has not taken a vacation. During his years of training, he has lost his existence. No wonder he is out of balance. We do not have solutions for Steve's current dilemma. There is probably not a single correct decision. Steve has a “schema” that he has learned very well from his training and from his mentors in thoracic surgery. His training has defined the rules and code of conduct for him as a surgeon, and he has embraced it so that it feels comfortable and familiar to him. For Steve, to break the patterned responses of this schema would make him feel uncomfortable and unfamiliar. He has learned to work hard, take his responsibilities of being a surgeon seriously, and put his need for self-care and his need to spend time with his family last. Similar to most individuals who have developed survival schemas by incorporating rules and beliefs for success or survival, he is good at selecting information to reinforce this schema and blocking or ignoring information to the contrary. However, we could propose a schema that may be more helpful to Steve, a schema that emphasizes the importance of valuing one's self, others, and the context for making choices. Adoption of this schema would create a dynamic, fluid, and balanced process for living. Virginia Satir [3Satir V. et al.The Satir model. Science and Behavior Books, Inc, Palo Alto1991Google Scholar] described this process of choice, which requires flexibility, balance and the ability to value one's self, others, and the context as “system-congruence” or “system-esteem.” It becomes possible to create stability in one's life when the triadic components of self, other, and context are kept in balance over time and there is fluid movement among these elements in relationship to choice and value. For example, in Steve's case one could argue the merits of Steve's returning to his medical practice to operate on the mayor and leaving Meg to vacation for a few days on her own. No one could deny the importance of putting a patient's care first, supporting his partner, or of protecting the reputation of his medical practice. Conversely, a case could be made for the importance of this time away with his wife. It certainly seems that it is a well-deserved and overdue break for the two of them. Also, what about Steve's own self-care? He needs down time as well. To get locked into a debate about any of these options would perhaps be getting so lost in the trees that one can no longer see the forest. The more important discussion is to identify the learned (patterned) responses to which an individual continually chooses: (1) self, and ignores the needs of others and the context; (2) others, and continually puts his or her own needs last; (3) context, in which work is consistently chosen over the needs of one's family and self; or (4) self and others, by completely ignoring the validity of the context. Whether Steve stays in the Caribbean with his wife or goes home to operate on the mayor, it does not become an issue unless he has developed a lifestyle pattern that consistently pursues only one choice. Life becomes unbalanced when individuals repeatedly choose one or two aspects of the triad (self, other, or context) and ignore the others. System congruence and system-esteem are present when an individual (as well as the other members of the system) wholeheartedly choose to value and respect all three system components. In a congruent system, Steve would not be locked into only one way of responding. The way Steve is presently functioning, he believes that his only choice is to choose context first. Although this schema of putting context first (his role as a surgeon, his care for his patients, and his responsibility to his partners) is what feels familiar and comfortable to Steve, he is also keenly aware of the painful cost to his marriage and to his own ability to be happy. It is unlikely that Steve would do too much damage to his relationship with Meg by decreasing their time together in the Caribbean, if she frequently (over the course of time) felt chosen and valued in her relationship with Steve. It is the repetition of never being chosen that creates the discord. Steve's schema of putting context first is more of a problem than the ethics of this one situation. Steve may have problems with his partners if they share his same schema of putting context first. Steve's partners would only be open to exploring other options with Steve for the mayor's surgery if their expectations (schemas) for appropriate surgical behavior allowed for the valuing of self, other, and context. Steve and his partners will have to relearn their schemas of choosing context first if they are going to develop balance and congruence in their lives. They need to share in and support one another in this change. Just as Steve's culture (surgical training and mentoring) produced and reinforced this schema, it may also have to change for Steve to be able to function comfortably within it. The possibility for change to this culture may have been handed to us by the Accreditation Council for Graduate Medical Education (ACGME) in the form of the 80-hour workweek for residents and the core competencies for education (please see the website at www.ACGME.org). Rather than view these as obstacles for training competent thoracic surgeons, we can try to embrace them as an opportunity to begin emphasizing balance in the way our residents are trained. At the same time, we can begin examining how well we can make these changes for ourselves as we become the role models for the future.