Psychiatry is a medical specialty in which being a complete person—with the insights, strengths, and experiences that come with the intentional balance of “loving” and “working” throughout the course of our lives—makes us better healers. This belief is a fundamental premise for our profession. If true, then the preparation of psychiatrists-in-training to live complete and fulfilling lives is important to educators in our field. We are faced, then, with the question of how we can meaningfully translate this objective (i.e., life “balance”) into curricula, clinical supervision, other educational activities, and the structure of undergraduate and postgraduate training.
Perhaps the first step is to understand better the vicissitudes of harmonizing aspects of one’s career and personal life as a psychiatrist. Four articles in this issue focus on this topic (1–4). These articles augment earlier contributions to the Journal (5–7) by focusing on the importance of taking into account personal and family needs and responsibilities when building a career.
Physicians are prone to overworking. Diverse factors contribute to this result, including the medical school selection process and a professional ethic that embraces hard work, excessive service demands, and fiduciary obligations to patients which promote the interests of patients over physician self-interest. Self-neglect appears to be more likely than not; one study (8) found that 35% of a cohort of practicing physicians did not have a regular source of health care. Moreover, the culture of medicine affords low priority to physicians’ mental health; barriers to seeking help are often punitive, including discrimination in medical licensing (9).
Psychiatrists, in particular, are vulnerable to occupational stress when working with emotional and behavioral disorders. Ours is an emotionally demanding profession. Among physicians, psychiatrists represent a group predisposed to career exhaustion or “burnout,” perhaps more so than their counterparts in other disciplines (10, 11). The divorce rate is also higher for psychiatrists than physicians in other subspecialties (12, 13). Unique to psychiatry, threats or assault by a patient and suicide are the most stressful adversities encountered in training (14).
Data regarding the physical and mental health of medical students suggest that it is not too early to begin focusing on self-care practices and personal well-being in medical school (15). In a study of 1,027 medical student-participants performed by one of us with others (16), 90% of students expressed a need for health care during medical school, but 48% reported difficulty obtaining health care, including 37% who said they were “too busy to take time off,” 28% who were “worried about cost,” and 15% who were “worried about confidentiality.” In this study, 57% of students who needed care did not seek care, mostly due to time constraints associated with training. Interestingly, in this study, 63% of students endorsed seeking some sort of “curbside consultation” or informal care, primarily related to convenience, time and financial limitations, and confidentiality concerns. In a longitudinal subsample of 94 medical student-participants (at one school) in this study, it was found that the need for care, difficulties in seeking care, avoidance of necessary care, and informal consultation practices all increased significantly by the time students were in their clinical years of training (17). Other studies have indicated that 20% to 25% of medical students have been depressed during medical school (18).
The story may be worse for residents. Medicine residents reported significant financial and emotional distress, and 35% had four or five depressive symptoms during residency (19). A study of internal medicine residents at a university-based medical center revealed that 76% met criteria for burnout on the Maslach Burnout Inventory (20).
Should we, as medical educators, be training medical students and residents how to balance the personal and the professional? Should we help our future colleagues learn how to be fulfilled in both spheres? Starting to teach the balance of the personal and the professional early in training would be consonant with the model of lifelong learning, in which we teach skills in school to be practiced for a lifetime. Assuming we are in agreement thus far, we need to figure out into which of the six ACGME (Accreditation Council of Graduate Medical Education) core competencies we may fit competency in balancing personal and professional life. Offhand, we may rule out “medical knowledge” and “clinical skills.” Significant others of physicians would probably guess “interpersonal and communication skills,” but the authors of the competencies were thinking about patients’ families, not our own. Then we come to “professionalism,” and here we run into a conundrum. The ACGME definition of professionalism states, “Residents are expected to demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest” (21, emphasis added). We affirm the primacy of the commitment to the patient: indeed, this is an expression of the traditional ethics of medical practice, which dictate that physicians commit to the well-being of patients, and to the prioritization of patients’ concerns above their own, and therefore, before their families’. Nevertheless, in doing so, physicians have often sacrificed their personal lives. They have also failed to be good role models for their patients—not eating and sleeping right, attending their children’s school performances, or seeing their primary care physician. Is there a “double-bind” here, to expect physicians to simultaneously self-sacrifice and to be good role models to patients? Common sense suggests that cultivating a healthy balance in life with appropriate attention to personal and family needs should lessen occupational stress. Moreover, by responding to their personal needs, psychiatrists might renew their enthusiasm for promoting the well-being of their patients.
Residency training has long been characterized by such self-sacrifice, with sleep deprivation, fatigue, and stress. Self-sacrifice as a symbol of devotion to patient care would put the motivation of any resident who complained in question. Is it not, however, a more recent ethic in medicine that involves a more nuanced approach—one in which we “practice what we preach”? Furthermore, some might argue that the call for duty-hour limits might be seen as a Hegelian solution to these opposing ethics. In the face of data that show that sleep deprivation correlates with medical errors, and because we seek to “do no harm,” first and foremost, work hours have been curtailed (22). Certainly, the forces creating the duty-hour limitations and their ongoing repercussions are complex and we are not doing them justice here, but a simplistic implication would be that self-sacrifice is noble until it negatively affects physician performance and possibly results in medical errors.
Duty-hour limitations challenge us to teach trainees to put the needs of patients first while simultaneously trying to maintain physician well-being. On a concrete level, medical educators now have to teach the knowledge and skills relating to an expanding array of medications and psychotherapies in fewer hours. Perhaps of even greater challenge, however, is teaching the attitudes supporting a commitment to excellence, responsiveness to patients, and continuity of care while telling residents to leave at a point before fatigue may develop. This is the paradox; this is the balance. It is a balance with which trainees will struggle for the rest of their careers. Are we able to teach them this skill—do we know how to?
Lifelong learning suggests that trainees should be taught to attain professional-personal balance the same way they will when they become practicing psychiatrists. A degree of speculation will be involved, given the constant change in the way psychiatry will be practiced over many years. Nevertheless, certain principles are likely to be invariant, and we offer some thoughts about boundaries, productivity and quality, and collaboration and teamwork.
Psychiatry residents learn about boundaries with patients. Can they apply that learning to the boundary between residency and other activities? The importance of this is increased by the many residents who are starting families or need to “moonlight” outside of the residency for financial reasons. As with patients, issues arise when boundaries are tested—when the carpool for one’s child falls through or when one can make more money by calling in “sick” and moonlighting elsewhere. The violations are not always against the residency. All practitioners need to continue their medical education, especially by studying and reading after hours. Residents need to find that hour each night when they can review journals or search the literature. Of course, this is like daily physical exercise—everyone agrees it is good for you, but we always manage to procrastinate. If residents do not learn this habit in training, when will they?
Physicians no longer have all the time they desire for patient care, whether that means staying late after being on call or giving more time for a patient visit. How much time one spends with a patient is no longer a measure of quality of care. Care is increasingly being measured in terms of outcomes and standards set by others. Similarly, in medical education, we are moving away from a time-based system of training toward a competency-based one (23), and trainees are being asked to demonstrate the quality of their learning. Measurement of quantity and quality will be a lifelong task. Being forced to choose between these may be confusing for residents. On the one hand, they may be told to see patients faster, and on the other, they may be told that their write-ups are cursory and lack depth. Attending physicians who advise and supervise residents need to help their earlier-career colleagues to think clearly about these trade-offs. Perhaps the same should be applied to the quality and quantity of time with loved ones.
Collaboration and Teamwork
Physicians increasingly have to work on teams, whether this is because of the complexity of medicine, the rise of corporate medicine, or the changing of shifts. Duty-hour limitations have underscored the latter. Clear and effective communication and the sharing of responsibilities have become more important than ever to the continuity of patient care. Feeling comfortable with getting home earlier may require greater care in communicating to the covering physician, including better articulation of your formulation of the case and treatment plan. Additionally, the covering physician has to earn the trust of his colleague that the patient will be in good hands.
Lastly, some thoughts from an administrative point of view. People’s behavior, even physicians’ (!), is influenced by incentive systems and thus administrative policies. Some policies are likely to encourage better balance of professional responsibilities and personal needs than others. A case in point would be maternity leave policies. In an informal poll by one of the authors (AKL), residencies appear to handle this differently. Some allow up to 3 months of leave without requiring delay of the graduation date. Others only allow the usual sick leave, with any additional time needing to be made up. Some residencies expect residents to make up all the call they missed during the maternity leave; others do not. The maternity leave policy implies a judgment about the proper balance between child-rearing and training duties. Thus the issue of balance is not just a personal one; it often is influenced by the values of colleagues, organizations, and society at large. One should bear in mind that the constraints of policies may limit the choices necessary for residents to learn how to make good life decisions—from personal and professional perspectives.
The irony, of course, is that residents are “yoked” together (as academic faculty often are) in a manner that means that one resident’s positive self-care (e.g., taking time off when ill) adversely affects the workload of another resident, a resident who then assumes greater stresses and encounters greater difficulty in his or her “self-care” or stress management. This means that wise educators (and administrative leaders) will build sufficient “degrees of freedom” in the system of training program (or faculty duties) to allow for some buffering of the stresses that may be experienced when colleagues take the time needed to care for themselves. A study of medical students (15) and an unpublished study of residents (Roberts 2007, in preparation) indicate that stigma and fear of poor grades and negative career repercussions cause trainees to hide their health concerns, which could be addressed by appropriate confidentiality and grading nondiscrimination policies. These are important tasks for program and institutional leaders. All of these tasks are, indeed, “easier said than done.”
Though we have been discussing the balancing of personal and professional life as a training issue, we also wish, like the four related articles in this issue of the Journal (1–4), to underscore the importance of respecting and supporting all of our learners. Programmatic and institutional responses should include early identification of medical students, residents, faculty, and all practitioners at risk of burnout or in distress, work-hour limitations, development of constructive communication and team-learning skills, the provision of readily available counseling, and the enhancement of psychiatrists’ professional fulfillment throughout their careers (24). Further, we should be looking to identify protective factors and to develop interventions that mitigate the effects of stressors.
We hope that the articles on balancing career and personal life in this issue of Academic Psychiatry stimulate future research: the nature and magnitude of this issue and the effectiveness of educational interventions. Until systematic studies are carried out, we will only be able to take preventive measures with face validity.