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Am Fam Physician. 2002;66(5):907-908

Birds do it. Bees do it. And, occasionally, overeducated and sleep-deprived medical students manage to do it. At some point in nearly every medical student's career, love happens. Whether it is the concept of “forever” or a momentary lapse of sanity, relationships during medical training do happen. The outcome of these relationships seems, at best, unpredictable. Many medical students are married or become married in the course of medical school, but statistics indicate that these marriages have a poor prognosis. In some medical specialties and subspecialties, divorce rates climb over 50 percent, while in others, 20 percent is expected.1 In 1992, the average divorce rate for first-time marriages of younger adults in the United States was roughly 40 percent,2 but this statistic is based on a cross section of a diverse population including high-risk marriages (e.g., teen marriages). Because the general population is a more heterogeneous group than the homogenous subset of physicians, it is difficult to interpret and compare these divorce rates.

What puts medical marriages at risk? Physicians-in-training are subjected to stres-sors like long hours and emotional strain, but so are many other professionals-in-training. There isn't a widespread divorce phenomenon in the military, for example, where the stresses of combat training and on-duty time are equal to, if not more than, those of medical students and residents. Yet, military families are usually strong, particularly those in the U.S. Air Force, which had a relatively low divorce rate in 1992 of 7.1 percent overall.3 This rate included the traditional Air Force husband-civilian wife pairings as well as dual-Air Force couples (a rising trend in all the armed forces) and Air Force wife-civilian husband pairs.3 This is in marked contrast to the divorce rate for psychiatrists (50 percent), for surgeons (33 percent), and a 22 to 24 percent rate for internists, pediatricians, and pathologists.3

The similarities between the medical and military lifestyles are remarkable. This is particularly evident in the Air Force, where officers tend to reside on base. The military has a strong internal culture replete with rituals, language, and symbols all its own, much like the medical culture; and both discourage, by the very rigor of their cultural demands, serious fraternization with other subcultura groups. The similarities between the lifestyles and demands of medicine and the military are numerous, but the differences in home and family life are significant.

As Arlie Hochschild argues in his work The Time Bind: When Home Becomes Work and Work Becomes Home,4 the idea of home is rapidly changing in American culture. Home is no longer the safe haven depicted in the television shows of the 1950s, but rather a noisy interlude filled with screaming children, a bitter and feuding spouse, and no reward or end in sight. Work, on the other hand, has become the American haven from home life.The workplace offers social gatherings, incentives for working harder, and a salary—a palpable measure of one's worth. The expectations of work are set, and many workers are socialized into the work setting by various means of training, step-wise promotions, and other standardized methods that organizations often set up as a way of promoting and maintaining a positive corporate culture. Conversely, there is no set way to standardize one's home life, and in an increasingly money-driven culture, there isn't as much incentive to do so when the demands of work financially overshadow what needs to be done at home.4

For physicians-in-training, this schism between home and work is especially sharp. The hospital literally becomes home for many medical students when they are on the wards, and it remains their permanent residence throughout much of residency. This lifestyle creates problems when these physicians eventually return to a more normal lifestyle with more subsequent hours at home with their spouses. Many physicians may feel more comfortable at work in the hospital culture, and the familial home may seem like a burden or a game with shifting rules and expectations that may seem to change daily. Spouses might feel abandoned by the years of long hours and the seeming lack of desire of their physician spouses to return home. This is especially a problem for spouses who are not a part of the medical field themselves and who do not understand why the hospital is so important in their significant others' lives. Many couples, however, who are both in the profession, may also suffer because they each establish the hospital as “home” instead of forming their own distinct marriage culture separate from the hospital.

Both types of marriages often use professional obligations such as additional post-residency training or building a competitive practice to remain in the workplace and to maintain the now-adaptive work-home schism for as long as possible.

This work-home schism is not seen in the armed forces to nearly the same degree with which it is seen in medicine, and the differences between them may help elucidate some possible solutions for the problems of the medical home. For example, in the military, effort is made to include the family in the military culture. There are Officers' Wives' Clubs, family-centered base sporting teams, along with base-wide activities that bring the military person and his or her family into the large-scale culture of the military and, specifically, the base. Most military bases have a home and family division that sponsors these activities and generally provides support for families. Most importantly, however, military families live together, typically on the military base, in close proximity to the culture that is placing demands on one or both of its primary members. Rather than isolating the military person from the family culture, the military seeks to combine the military and family cultures. Indeed, the military is incredibly proactive in this regard, funding the Military Family Institute at Marywood University in Scranton, Pa., an excellent center for marriage and family research, which receives several million dollars in government funding each year to perform research on the state of military families.

How different would hospitals be if they offered a proactive “Work and Family” office for residents and their families? Many hospitals have similar divisions, but very few are diversified or funded enough to offer more than an annual hospital picnic for residents and their families. Given the stresses of the job, many students, residents, and their spouses could certainly appreciate access to inexpensive, excellent marital counselors like those offered to military spouses. Subsidized day care is often available on-site at hospitals, but hospitals could be more proactive by promoting activities for children and parents at the hospital, or offering inexpensive access to local family activities to encourage parent-child interaction.

Improving and strengthening family relationships would not only decrease stress but also would provide an improved support network for physicians-in-training. Given what is required of these medical “soldiers,” requesting hospitals to provide emotional and social support for their families does not seem too much to ask.

This quarterly department features essays written by medical students and family practice residents. Contributing editors are Amy Crawford-Faucher, M.D., a family practice resident at the Fairfax (Va.) Family Practice Residency Program, Sumi Makkar, M.D., resident representative to the Family Practice Editorial Board and Terrence J. Joyce, student representative to the editorial board.

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Copyright © 2002 by the American Academy of Family Physicians.

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