Last Saturday, I had the honor of speaking at the Florida Hospital Physician Summit, Revitalizing the Heart of Your Work, with Drs. Rachel Remen and Ben Carson.  Dr. Remen, who teaches the art of healing to students at UCSF, commented on how first-year medical students who are open, sensitive, and intuitive (qualities one might like to see in one’s physician) become ground down during 4 years of medical school and 3-5 years of residency.

Her observation reminded me of what a physician colleague wrote in an as-yet unpublished essay:

My background was typical. Growing up in a home where success meant everything, I went straight from college to medical school, where I was elected to the AOA honor society. I competed for the best training programs and never took any time off to travel, experiment with different career options, or spend time learning about myself. I performed well in all tasks and remained focused on only one thing – medicine. I married during my final year of cardiology fellowship and quickly started a family. During all this time, I took advantage of opportunities for professional, but not personal, growth. I directed all my energy toward the science of medicine.

My partners and I worked well together, sharing responsibilities and growing our practice. Work for me was all-encompassing. My wife and family became secondary characters in my life as I focused my attention on the practice. I avoided introspection and anything else that would stir up feelings. Work became my escape.

I was able to hide my fears behind my mask. On the outside, I was joking and self-assured, but I knew that something was missing on the inside. I could not admit that I was afraid of not meeting expectations until nearly twenty years later. My father, a retailer, and my mother, a nurse, placed physicians on a pedestal. I grew up watching Dr. Kildare, expecting that I had to be available, kind, and most of all, able to solve patients’ problems within 30-60 minutes. I learned that I could wear my mask of appearing happy to avoid my feelings. Everyone with whom I came into contact accepted the mask of the easy-going cardiologist.

Doing became habitual behavior. I felt like an addict. I chaired hospital committees and, as a result, spent even more time away from my family and myself. Meanwhile, the practice was growing rapidly to support a new catheterization lab and cardiac surgical program. We opened offices in other communities and took turns sleeping in hotels until we could hire additional partners, growing to fifteen cardiologists.

My belief in living my life as I had been taught was unwavering. I accepted the notion that I would work hard, make enough money to satisfy my family’s needs, and become a prominent member of my local community. After all, that was what I thought being a physician was about.

My alienation from my family grew as my ability to feel emotions stagnated. As I became busier, I withdrew more. I had reached the point that was viewed as a success by almost everyone. I knew deep inside that something was wrong, but I could not identify what it was. Meanwhile the practice flourished, adding new services and expanding to twenty-one cardiologists.

Juggling all these responsibilities and trying to remain a loving husband and a devoted father began to take a toll. I struggled to wear the mask of external success and felt that I was going through the motions. It was becoming more difficult to keep hiding behind my mask. I felt that I could not let anyone know of my personal struggle for fear of being judged a fake or a failure. 

‘What would people think of me if they knew what I was really like?’ I wondered.  It was exhausting to maintain that mask because it sapped my energy to be living a lie between what being a doctor was supposed to be and what I was actually doing and feeling.

In “Inside the Mind of a Physician,” page 23, Dr. Herdley Paolini displays a table with one column devoted to what you see and the other to what you don’t see. For example:

• underlying a physician’s strength and omnipotent attitude may be insecurity and fear of making a mistake
• behind the mask of arrogance may be fear of not knowing or being judged not good enough
• stoicism and aloofness may reflect a physician’s vulnerability and fear of pain or loss
• humor can hide anxiety and fear of rejection

According to Dr. Paolini, group loyalty may require physicians to deny pain or glorify it to justify their membership.  As evidenced in the above example, some characteristics that make undergraduates promising candidates for medical school (like work capacity) may increase their susceptibility to the psychodynamic issues described above.

Unfortunately, when physicians are unaware, in denial, or feel trapped, they may have little reserve to cope with professional and family stresses and find the holiday season burdensome rather than pleasurable.  As discussed in Workplace Burnout, physicians can benefit from periodically taking stock of where they are and how they are feeling.  Although it may seem counterintuitive, stress may be a blessing if it helps physicians recognize the difference between their expectations and the way that situations unfold.

Fortunately, the physician listened to his wife and daughter and sought assistance:

I began a new journey of awareness.  I learned to forgive myself and others. I also learned to reframe, to reexamine life events with a different perspective that allowed me to reinterpret them. I learned of the preciousness of the present moment and that time spent regretting the past or fearing the future made me blind to the present.

Keeping focused on the present moment became an invaluable coping mechanism. I learned to listen to one patient at a time and to allow that interaction to proceed as it was supposed to rather than allow the previous patient or the next patient to interfere.  In the times when I can ignore that inner voice that is judging the past or fearing the future, my role as healer flourishes. 

Admitting that we do not have the answers and turning to others for help reflects strength, not weakness.  Interventions may be career- and even life-saving.  If the holidays cause you to see the world as gloomy and you doubt that you can continue or want to continue, please be strong and seek/ accept the assistance of others.

Kenneth H. Cohn, MD, MBA, FACS

© 2009, all rights reserved

PS: This will be my last blog for 2009. My son, a senior at Purdue in the Naval Reserve Officer Training Program, will begin his Naval aviator training soon. Our focus will be on family from Thanksgiving through the end of the year.