The Time of the Three Dynasties: Reflections on Imbalance in the Practice of Medicine

“From the time of the Three Dynasties men have been running in all directions. How can they find time to be human?”

Chuang Tzu [1]

My brother-in-law Robert died last week. He was 41.

No one knows exactly how the accident occurred, but his family, and other farmers, could guess the specifics and especially the cause. He had a wife and six young children, worked three crop farms, kept some cattle, looked after his mother and her place, and was the executor of his uncle's contested will. Even to a doctor he seemed enormously over-extended.

Robert's wife said his sleeping habits had suffered noticeably for months because of the pressures he felt, and he slept little the night before he died. Yet he worked all the next day, and on that midsummer evening-feeling that there was still more that had to be done-he took a tractor-mower and went to clear some thick brush around the fields of his mother's farm. A line of fence wire got caught in the large blade and at 8:30 p.m., knowing better, he positioned himself under the heavy piece of equipment to free the wire. Then something shifted and slipped, and he died. There could be no sophisticated medical intervention, not even a resuscitation. He was dead within a few horrible minutes, his chest crushed, his mother there to witness it after his agonized call. The sight of his lifeless body was so disturbing that people gathered at the scene would not allow his wife to look at him but only to hold his cold hand as it lay exposed at the edge of the tarp that covered him. It took six men to lift the mower off his body.

The pain of his family was indescribable, unknowable even in its essence except perhaps by others who have had a similar loss. There had been no similar loss for these sufferers, though. Nothing they had experienced could assist them in their grief, nothing could assure them that the pain they felt was survivable. In the early days after Robert's death, his wife's face reflected more daze than anguish; his children were more fidgety than tearful, at least in their public moments. Those of us around them knew that we could fill their time but that there was really nothing substantial we could do to fill the void his death had caused. Some in his community, perhaps not knowing what else to say, remarked, “Life goes on.” Yes, but never in the same way for those who loved him most.

Was Robert overworked? Under too much stress? Finally careless? Almost surely “yes” to all of these. Everyone who knew him wondered whether he had to die. Were there not at least a few critical periods when he could have stepped back, seen differently, changed his course, and perhaps saved his life?

For physicians, is there a lesson here? The similarities, you must agree, are striking: heavy, often isolated, and (seemingly) imposed workloads; the pressures of time, achievement, income, and other responsibilities; the primacy of work over all other interests, although the principals often claim otherwise. This was Robert's reality, and it is also ours. What drives us to it? As humans in the late 20th century, our identity seems largely defined by what we have, what we do, and how we learned to do it. We understand ourselves this way, too. Physicians may be examples of the very worst kind, typically taking not only our work-and ourselves-too seriously but also working too long, too intensely, and at a pace we would never advise or even allow our patients to maintain. In medicine, at least, there is a point beyond which this behavior is hypocrisy, not valor. How much work and reward are enough? How much is too much? Who has control? Do we know the real cost? Who pays the price?

When I was a medical resident, I began to hear bothersome comments from older physicians about the practice of medicine after the training years. “Medicine is a jealous mistress,” one professor commented, reflecting, among other things, the maledominated medical structure of the time.

“I always tell the residents' wives not to expect that the long hours, absence from the home, and hard work will change once their husbands go into practice,” he said. This was the same man whose wife had found an undelivered letter in their daughter's bedroom drawer after she went away to college, telling him that over the years he had sacrificed his family for the sake of his medical practice and had thus stolen something from her. (Another letter, forgiving him years later, was carried daily in his briefcase for the rest of the time I knew him.)

Other quotes about medical practice stayed in my memory and communicated recurring, dissonant themes. For example, a partner at a hectic cardiology practice that I joined made the following statement-memorable especially for its prophetic latter phrase-to my wife when a sprinkler head on our lawn didn't work: “Well, you had better learn to take care of these things yourself, because he's not going to be here.”

Also telling is a quote from my wife to a neighbor when I left that practice and came to Denver by myself for a month to find a house for our family: “What's like to have my husband gone? Well, it's not much different from when he was here.”

A prominent thoracic surgeon in Houston, the author of at least one surgical text, told me that his goal when he left the house each morning was to get back before the 10:00 p.m. news.

“I never made it,” he said, and after several years of this he finally gave up a very lucrative and prestigious practice in cardiovascular surgery for one in preventive medicine. I last saw him here in Denver a few years ago with his wife, watching their son play college lacrosse. I think of him as one of the most courageous physicians I have ever met. His willingness to undergo not only a change in type of practice but also a deeper, more radical change in personal and professional identity-not to mention his ultimate success at it-is admirable, but it is also just one example of the many challenging but less demanding opportunities unfolding in the field of medicine today.

Other stories over the years-usually told in a matter-of-fact, lamentable tone or with outright nostalgia during placid moments in the doctors' lounge-reinforced these early impressions. A senior cardiologist's daughter told him, “We don't remember you until we were about 8 years old, because that's when we were old enough to stay up until you got home.” Another doctor invited a grown daughter to spend an afternoon with him and was told, “You know, Dad, you didn't have time for me when I was young, and now I don't have time for you.”

Finally, when one of my current partners was in an earlier, busier practice and was gone much of the time, his son asked his mother, “Did Daddy die?”

My medical school's 20-year reunion information form requested data not only on the location and type of practice the graduates had but also information about their spouses:

“#1.____________________

#2.____________________.”

These vignettes are all about accomplished and upright individuals who are of great service to their patients. The stories' theme of imbalance and its consequences does raise the question, however, about whether our professional focus is one of the “shadows cloaked in light” that Baltasar Gracian warned us about in the 17th century [2]. Are we so dedicated to the unquestionably honorable mission of enhancing the lives of our patients that in some ways we actually impede-or harm-the lives of others, including ourselves?

At my brother-in-law's wake, several people commented that life is short. Short or not, as a Tibetan Buddhist friend pointed out, life is finite, each moment irretrievable, and although we know this we don't believe it. If we did, our behavior would change. We wouldn't waste time in any way, especially in overwork and preoccupation and stress. Almost anyone who has had a serious threat to his or her life or health will confirm this. As my brother-in-law's death shows, these things are killing our sensibilities, our culture, and ourselves.

Robert's neighbors would say that besides being a hard worker, he was also lucky, inheriting good land, farm machinery, buildings, and money. Like us, he got his wish, but somehow it all became too much to handle. With him it might have been the result of expectations based on the work habits of generations of farmers before him, coupled with his own way of coping. He had imagined no other way. Eventually it all became harmful-fatally for him and horribly for his family.

I think it's so with many physicians, too, who would otherwise not identify with him. Amidst all the excitement, professional satisfaction, glory, and possessions, there is often an awareness of some profound yet distressing reality that all of these things cannot satisfy: perhaps an illness; an awareness of children “suddenly” grown and distant; spouses often gone or at least living separate lives; some of us, perhaps finally introspective, longing for opportunities missed. Golden handcuffs are still handcuffs. Our “successes” call to mind a passage in the Tao Te Ching that speaks of a water-bearing vessel that tips over when filled to the brim but remains upright when filled to a lower level [3].

All is not darkness in the practice of medicine, certainly. Besides its inherent value to our patients, the very privilege of participating in it, the sense of achievement felt after completing seemingly countless years of study and sacrifice, the satisfaction and humility generated by assisting others in a time of need, and the opportunity to provide well for one's loved ones are just a few of the benefits that come to those in its service. Not surprisingly, many argue that there is not a widespread problem with the way the modern medical life is lived, or, considering the degree and pace of change in its practice, that there is little we can do to gain control over it. Others insist that there is still much we have to learn about how to do it well.

Is there imbalance in our individual practice of medicine? Do we need to “save ourselves from the world of our time,” as Thomas Merton [4] suggested? Are the principles and ideals required for balance irreconcilable with millennial realities? We each have to answer this for ourselves, taking the time to think about it at all, of course. For me, lessons learned over the years from my own and others' experiences have evoked a profound understanding of and appreciation for what I value at the deepest level, as well as philosophical and practical changes based on that awareness: continuing the commitment to excellence in patient care yet valuing relationships with loved ones over professional concerns; taking Wednesdays off; dissociating myself from a consuming practice; ceasing to do interventional cardiology; getting involved in community work; and committing to a simpler lifestyle. The effect of making these sometimes difficult choices has been a less remunerative but otherwise richer and more vivid life for my family and myself.

But in this plurality there is no simple or uniform answer to why we structure our days or ourselves the way we do. A specific occurrence like my brother-in-law's tragic death compels some level of personal reflection for all of us who knew him and, however horrible, can have meaning for others as well. His life and death speak strongly to me, and I hear more as time passes: Life is finite; we are driven, often by things inapparent; we cope-sometimes not in the best way, although we may think in the only way; our actions not only affect but define others; and, even with the enormous amount of information and experience in our consciousness, we are all too often shamefully unaware of happenings in even our most intimate relationships, let alone elsewhere. In epidemiologic terms, the condition of imbalance in the practice of medicine seems to me pervasive enough to be considered endemic and even stereotypic. Its recognition and treatment, of course, are intensely personal.

How are you? And yours? What would they say Do you dare ask them?

• Copyright ©2004 by the American College of Physicians