It is an interesting paradox that those who seek to be healers can be emotionally, physically and spiritually injured or killed by the stressors of their own work. Angry patients, managed care denials, Medicare audits and even the demands of your daily routine are among the stressors that make practicing family medicine seem unmanageable sometimes. But you can make your life better by addressing the one thing you truly have some influence over: your internal self. Theologian Paul Tillich called this “living from the inside.”1 Although the following 10 imperatives are not always easy to implement, they have the potential of bringing great personal and professional rewards.
1. Resurrect “dead zones.” Some physicians are just existing, or enduring life, and are no longer really living. To survive, they have shut down parts of themselves – their emotions, their compassion, their relationships with others or their family intimacy – creating “dead zones.”2 While this may be a valuable survival skill during times of crisis, doing it regularly can become extremely destructive. If you have dead zones, allow those parts of your life to awaken again. It is vital to find a way to nurture yourself and keep yourself in an atmosphere of growth.
Possible interventions. Recall an intensely positive experience in your life. What made it so positive? What about you made the experience possible? Are there any barriers to this type of experience in your life today? Focus on the potential for good things to develop in your future rather than on bad things that may be happening now.
Living from the inside” can make your life and your work more meaningful.
Rediscover your calling and regain your focus as a family physician so that medicine will be satisfying for you in the long run.
Self-awareness will allow you to heal yourself as you heal your patients.
2. Reclaim calling. Plato believed that each person comes into the world with a special calling. As a family physician, you need to find or rediscover your calling – whatever it is that puts your work into a larger context – if you want medicine to be satisfying for you in the long run. Research has shown that those who have a calling experience less stress. When you’re floundering, your calling can be a beacon that helps you to refocus.
Possible interventions. Reflect on why you decided to practice medicine. What drove you to pursue this field? Perhaps you’ve always felt as if you’re in a position to help people in a special way. Think about the times patients told you about the positive impact you had on their lives. Review notes and cards of appreciation from patients, or start maintaining a collection of these positive stories.
3. Reflect on meaning. Carl Jung wrote that “the suffering we cannot endure is that which has no meaning.”3 We can learn from people who have experienced the extremes of human existence and have had their assumptions about life shaken or shattered. They survive by making some kind of meaning out of their traumas4 and find they have the freedom to choose personal attitudes and find purpose in any given situation. A large component of an individual’s mental health is based on attitude, our philosophy of living and the meaning we make in our lives. It is important to take time to reflect on the meaning of your life and work. As Stephen Covey writes, “A meaningful life is not a matter of speed and efficiency.”5
Possible interventions. When medicine is very stressful, what other area of your life do you move toward for meaning? Perhaps it’s volunteering with a youth organization where you can have a positive influence. Such involvement can give you the meaning and purpose you need to face other difficult areas of life.
4. Remember transcendence. The monotony of everyday life or crises that occur sometimes have to be transcended so that we can see the bigger picture. Failing to see the bigger picture can result in burnout; transcending life can help you survive. For some, transcendence may involve spirituality. For others, it may involve noting the extraordinary in ordinary events or finding humor in them.
Possible interventions. Is there a religious institution that can give you some organization to your religious or spiritual life? When have you recognized God or some larger power or influence in your work as a physician? Review each day noting any ordinary events that had extraordinary meaning for you. Start a collection of jokes or cartoons or, better yet, life events that strike you as humorous, and share these with others at work.
5. Regain focus. If you have been focusing on the distractions of managed care and other stressors, you may look back at family practice only to find that its beauty – the practical focus on the patient – has become blurry. This focus needs to be regained. Family physicians need what ethnography scholar James Clifford calls a “contact zone”6 with patients. A contact zone is a sacred space of exchange and negotiation between two or more worlds – in this case, that of the physician and the patient. It involves the physician taking the time to learn who the patient is and what is important to him or her. Renewing your interest in the psychosocial part of patient care can help you regain your focus. It encourages you to maintain a sense of wonder about people and find out what makes your patients who they are. As a physician, if you value the sacred space with patients and affirm each patient in some way, the law of reciprocity will somehow result in affirmation for you as well.
Possible interventions. Choose a few patients in your daily schedule with whom you plan to create a contact zone. Make a special effort to be curious about some part of their lives other than medicine. How do they keep going? What is their family life like? Make an affirming statement to each of them.
6. Find refuge. It is important to find refuge, or sanctuary, in life outside of medicine. You may find it in nature or in a more formal setting, such as a church, temple or mosque. Or you may find it by simply sitting in a rocking chair. Wherever it may be, this place of refuge should allow you to quiet your soul long enough to hear different voices of life than you hear in the hustle and bustle of the normal world.
Possible interventions. Take a casual walk at a nature reserve and focus on the details of the plants and terrain as you approach them. What sounds do you hear? Can you find a special retreat to which you can return often? Can you take a “mini vacation” at some point during the workday and visit peaceful places in your mind’s eye?
7. Renew discipline. Often there are no quick fixes for what ails your patients; lifestyle changes have to be made. The same is true for physicians. However, many physicians who are disciplined in their professional lives don’t practice this kind of discipline in their personal lives. It is often too easy to think that you do not have to do the same self-care that your patients do or that you are just too busy for it. But you need good exercise and health habits just like everyone else, perhaps even more so because of the stress of your profession.
Possible interventions. If you were your own physician, what would you honestly tell yourself about needed lifestyle changes? If you do not have your own family physician, get one. Enlist the assistance of a physical trainer to keep you on target with physical and dietary goals.
8. Reinforce patience. I have seen residents quickly fall into tremendous debt after graduation as they try to satisfy pent-up desires that their educational pursuits forced them to deny. Although, as a physician, you may be used to making things happen quickly, life does not always work that way. Financially and otherwise, we all need to be reminded to take life one step at a time. Progress begins with small steps.
Possible interventions. Read something nonmedical or relax for just 15 minutes a day, and over time you’ll notice yourself becoming more patient in your professional and personal lives. Prioritize and make a timeline for your long-term goals, recognizing that they must often be delayed.
REFLECTING ON LIFE AS A FAMILY PHYSICIAN
Use the following questions to help you reflect on your life as a family physician and identify ways you can make it better:
Describe a good experience you have had as a family physician. What made it good? What feelings did it generate in you?
Of the 10 suggestions described in the article, which ones do you have the most trouble with? Do those problem areas affect your overall lack of satisfaction with family practice?
How long has it been since you made a positive change in your approach to life? Can you describe any positive changes you have made recently in your interior” life (values, spiritual life, personal priorities, etc.)?
Describe one positive change you could make in your life. What keeps you from making it? Are you willing to move forward toward this change? With whom could you share this decision as a way of reinforcing it?
What helps you make family practice doable? What do you have control over that could make it more doable?
9. Reduce reactivity. Deal with stressors proactively rather than reactively. A reactive stance keeps you in a defensive position, and the intensity of hyper-alertness wears you down. This can lead to dysfunctional responses, such as chronic negativity and pessimism, affairs, substance abuse, chronic anger or suicide, or it might cause you to leave medicine. Roger Merrill, coauthor of First Things First: To Live, To Love, To Learn, To Leave a Legacy, says, “If you spend your time blaming your circumstances, the environment, your profession or the expectations of others, it won’t get any better.”7 Instead, concentrate only on the areas of life you can do something about. It is important to be able to make this distinction and realize that many things are beyond your control.
Possible interventions. See a counselor to assist you in directing your anger and reactivity in a more positive way. Get involved in a physician support group so that others can assist you in sorting out the things you need to let go.
10. Recover self-awareness. The familiar phrase “physician heal thyself” requires that physicians know themselves first. In Empathy and the Practice of Medicine: Beyond Pills and the Scalpel, Rita Charon writes of the physician’s need “to allow for our own injuries to increase the potency of our care of patients, to allow our personal experiences to strengthen the empathic bond with others who suffer.”8 This type of self-awareness may help you to heal yourself as you heal your patients. Everyone struggles with their own imperfections and limitations, and giving story to these is vitally important. Acknowledging your woundedness to support groups or friends can be a step toward maintaining health. By becoming self-aware, you can stay in touch with your humanity, give up on control and perfectionism, and move from the role of expert to a more collaborative approach in your career, your family life and your other relationships.
Possible interventions. If you have been keeping all of your struggles to yourself, gradually begin to share with a trusted friend. Pause to reflect on your reactions to patients.
FPM ARTICLES ON PHYSICIAN WELLNESS
“The 12 Commandments of Wellness.” Bintliff S. May 1997: 97–98.
“How to Invest Your Time to Get Maximum Results.” Flanagan L. January 1997:46–51.
“Rediscovering the Joy of Family Practice.” Thiedke CC. November/December 1996:32–40.
Making it work
As family physicians, you will always have to deal with stressors, but perhaps you can find rewards that will motivate you to carry on despite them. These 10 imperatives can help you find more positive approaches to dealing with the stressors inherent in your work as well as more internal rewards. They can help to make family practice doable in everyday life.