Professionalism guards against neglecting self
■ Why is the physical and mental health of physicians important?
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to firstname.lastname@example.org, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted Aug. 16, 2010.
What can I do when I know I'm not at my best? What is the best protection against physician impairment?
Reply: A short story, "Old Doc Rivers," by physician-poet William Carlos Williams, portrays the tension between a physician's dedication to patients and his inability to recognize and respond to his own health-related impairments. Doc Rivers would "go anywhere, anytime, for anybody," and his flashes of brilliance in diagnosis and therapy make him a local legend. Yet his punishing schedule exacts an immense toll, and he ends up ruined by alcohol and drugs.
Through the story, Williams confronts physicians with a vital question: Where is the appropriate balance point between caring for patients and caring for self?
Dedication to patients is necessary and appropriate, but not to such a degree that it prevents us from attending to our own needs. Good health plays an important role in enabling us to perform at our best, and poor health may undermine fitness to practice medicine.
Patients, communities and the profession of medicine have a legitimate interest in the health of those in whom they place their trust. And as physicians, we bear a duty to recognize our own health-related limitations and take appropriate steps to safeguard those who depend on us. No patient should be harmed because a physician is sleep-deprived, febrile, intoxicated or simply in too much distress to perform adequately. Depending on circumstances, ensuring our patients' safe, quality care may entail rescheduling a patient visit or arranging for a colleague to provide care. What might seem at first glance an admission of weakness turns out to offer powerful testimony to the strength of a physician's dedication to patients.
Physicians must be prepared to assume the role of recipients, not just providers of care. Some people prefer to view doctors as impervious to the injuries and ailments that beset them, regarding the white coat at times as a cloak of invulnerability. Yet physicians' lifetime mortality rate is no lower than that of patients. By recognizing that we are cut from the same mortal cloth as our patients, we lay the groundwork for a deeper patient-physician relationship, putting the welfare of patients above our own determination and pride.
How well do we succeed at recognizing our vulnerability? Are we sufficiently in touch with the connection between our own health needs and the interests of our patients to discern when the former jeopardizes the latter and take the necessary steps to ensure that patient needs are met? Equally important, are we mindful of signs of impairment in colleagues and willing to intervene as needed on patients' behalf? Medicine remains a profession only so long as it monitors its own ranks. Physicians have a duty to watch out for one another and to subordinate the understandable desire to avoid embarrassment or confrontation to the good of patients.
Yet we should be careful, lest we forget the limits of health as a medical priority. Reasonable patients would never choose a physician solely on the basis of his or her health status. We cannot infer a high degree of medical knowledge, skill or dedication from a slim waistline, a low blood pressure or an ideal serum lipid profile. In fact, an excessive preoccupation with personal health might prevent physicians from devoting sufficient time and attention to the needs of patients. From the patient's point of view, there is comfort in knowing that a physician is prepared to skip meals and sacrifice sleep or a workout at the gym to attend at the bedside.
Attention to our health has other limits. A system that does a good job of protecting patients from physicians' impairments may not fare so well at promoting excellence in medicine. Like a driver education program that focuses on preventing traffic infractions, it may draw attention from equally important questions: What is our destination? How are we getting there? How fulfilling is the journey? No driver would choose to get a traffic ticket or injure other people, but there is more to a successful journey than arriving safely. Physicians would never select as their epitaph, "He took great care of himself," or "She was never impaired."
Excelling in medicine
The most worthy aim of a life in medicine is not to satisfy minimal standards of safety and competence, but to excel. Focusing too much attention on impairment and its remediation may distract us from performing at our best. We should not ignore our health, but we need to attend to it in a way that recognizes the prevention, diagnosis and treatment of impairment as a byproduct of a higher pursuit.
The best protection against impairment is not an infallible system of detection and enforcement, but an approach to the practice of medicine that promotes genuine fulfillment, enabling physicians to do to the best of our abilities those things that are most worth doing.
We do better work when we have good work to do. Such work is characterized much less by extrinsic rewards, such as power, fame and money, than by the intrinsic rewards of the work itself. Are we growing and developing through our labors? Are we practicing medicine in a way that accords with the ideals that drew us to a career in medicine in the first place and have animated this venerable profession throughout its history? And, most importantly, do we sincerely believe that we are making a significant difference in the lives of the patients, families and communities we serve? If the answer is yes, then impairment is much less likely to become an issue.
In my experience, physicians who derive genuine fulfillment from the pursuit of medicine's highest aspirations are less likely to become discouraged, suffer burnout and neglect themselves. Far from finding their work a burden, they cherish it as a privilege. They need not flog themselves from day to day to keep going, because they are drawing from one of the most invigorating wellsprings of inspiration available to human beings: the sense that they are achieving their full potential and enriching the lives of others. We may make a living by what we get, but we make a life by what we give.
The word "health" derives from an Old English word that means whole. To become and remain whole, we need to approach health like a symphonist. Merely getting each piece in perfect working order is not enough. We need to be virtuoso musicians who know how to play their parts well, in ways that harmonize with every other performer. We may get the cells and organs in good working order, but if the body is not aligned with the mind and the soul, the result will be cacophony.
The greatest threat facing medicine today is not a deficit of sleep, nutrition or longevity. Nor is it a deficiency in health care payment or even the erosion of professional autonomy. The greatest threat facing medicine today is a deficit of inspiration, what we might call "inspiration deficit disorder." To recapture, sustain and augment inspiration, we need to see our lives as part of a larger story of healing. It is our privilege, for a time, to breathe new life into healing's timeless aspirations in our daily work.
The vitality of physicians and the wholeness of the profession itself depend more than anything else on our ability to reconnect with the inherently inspiring aspects of the practice of medicine. If we can position ourselves on the appropriate trajectory toward this higher end, the lesser goals, including the health of physicians, will find their proper orientation.
Richard Gunderman, MD, PhD, professor, Indiana University School of Medicine
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to email@example.com, or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.