People drawn to careers in medicine have unique personality traits and aptitudes that include high intelligence, compassion, inquisitiveness, and sensitivity to others. But we are also extremely competitive, driven, perfectionistic, and sometimes even obsessive-compulsive.
Many traits that enable us to endure medical training and the daily challenges of our profession also cause us considerable personal grief. In Part 1 of this series (see Holistic Primary Care, Winter 2004) we explored our tendencies toward over-caring and perfectionism. In this part, we'll look at competitiveness, safety-seeking, and other traits that lead to social isolation felt by many physicians.
The underlying question behind perfectionism is: "Am I Enough?" But this question and its underlying fear often take a different shape: "Will I Survive?" In this guise, the fear drives us to compete.
We medical people are some of the most intelligent people in our communities. Most of us found grade school and even high school to be pretty easy. Then came college. Suddenly, we were surrounded by people with the same aptitudes and ambitions. We knew that not all pre-meds get into medical school. All of that led to some variant of this inner dialog: "I have always wanted to be a doctor. My parents and friends expect it of me. I can't let them down. They've already invested so much in my education. I must be one of those who makes it!"
For some, this led to cheating. For others, it led to nastiness. For most, it simply caused intense, chronic anxiety to which we responded by pushing ourselves harder. I am sure you can remember leaving a difficult exam, only to meet a fellow student who said, "No big deal." Suddenly, the anxiety intensified. You started pushing even harder. Others didn't seem to be working as hard (mostly they were just pretending), and this only fed the "Am I enough?" voice.
This cycle—anxiety leading to pushing leading to more anxiety—worsened through medical school. By the end of your education you spent 8 fearful, competitive years doubting your abilities. And if you think those attitudes just drifted away once you became a doctor, think again.
Type A Behavior
Competitiveness, perfectionism, anxiety, and high goal-orientation are significant components of what Meyer Friedman, MD, defined as the "Type A Personality." As an example, let me describe how I got into medical school.
In college I had a GPA of 3.5. Not bad, but in the late 1970s when med school competition was extreme, a 3.5 wasn't going to cut it. My 30-plus applications led to 30-plus rejections. This was extremely frustrating. Sure, my GPA was less than 4.0, but did these jerks know what a great guy I was? Or how caring? This is a typical angry Type A response.
As a card-carrying Type A, I took a one-year non-thesis master's in physiology. I figured if I scored a 4.0, I'd be a shoe-in to med school. Nope! After 30-plus more rejections, I decided that if I wanted to go to med school, I'd need to work in one. So I went door-to-door to all the physiology labs at the DC-area medical schools. It worked! I got a job. By the next year, I was in medical school.
All of this seemed perfectly reasonable at the time. I had a goal and I used all my wits to achieve it. I persisted over 3 years and obtained an additional degree just to accomplish that goal.
We Type A people are opinionated, judgmental, and pressured to succeed. We are chronic multi-taskers, always in a hurry, often aggressive beyond need. We speak in clipped patterns, often forcing a smile to cover our competitiveness. We seldom trust others to do a job right, need to prove our self-worth, and seek recognition. These tendencies seemed necessary to survive our training, but do they serve us well today? Type A behavior is strongly linked to heart disease and mortality, so it certainly doesn't serve our health. It is not too good for happy family relations either. We hold on to it because it is associated with societal and financial success. We fear that if we let our type A behavior go, we will not succeed.
The average American businessperson changes jobs once every 6 to 7 years. We, in medicine, chose a career where a job change is infrequent, if ever, and often traumatic if it does occur. Why is this?
Individuals attracted to medicine are attached to an unwritten societal contract stating that when one becomes a doctor, one spends a life in service to the community. We accept these terms for four reasons: 1) It is socially esteemed as a "right" thing to do; 2) We are driven to be physicians so strongly that we'll sign on for almost anything; 3) We want job security; and 4) We are averse to change. The last two are the main drivers of the "contract." People who go into medicine do not want to change jobs. We want guaranteed high income. We give up 8-plus years and expect society will provide us with material security and high esteem.
Unfortunately the contract is falling apart! The financial security of a career in medicine is dwindling. Our patients change doctors frequently. We get sued more often and more randomly than ever, and our income, relative to overhead, is decreasing. This adds to our stress, and as safety-seekers, it rocks our very nature. It also violates our innate sense of justice: We acted in good faith, yet society broke its "contract" with us. We must learn flexibility and resiliency.
Social Isolation & Emotional Dissociation
Social isolation is associated with increased risk of cancer and heart disease, and it is highly prevalent amongst physicians. It starts when we are very young. By nature, many of us were quiet and studious. Face it, we were nerds or at least closet nerds. We were self-motivated, deeply engaged in academics, and didn't gravitate toward team play, all of which created a sense of isolation.
Now, take young people like this and put them in a program where 80-hour weeks are the norm, at the very life-stage when everyone else is having active social-lives, "real world" jobs, and families. It is not hard to see how this further enhances social isolation. And, if those young doctors-to-be are afraid to discuss their mistakes, daily challenges, and fears, the isolation only gets more extreme.
Conventional medical training is highly dysfunctional. It exaggerates the traits we already described, typically at the expense of compassion, sensitivity, and social connection. It seems a basic tenet of our training that if you overload trainees with responsibility and information, they'll rise to the occasion. And we do. We work longer, get paid barely enough to survive (especially given our debts), and still we must see ever more patients.
One way we cope is to become emotionally dissociated. It begins in anatomy lab. No one enjoys the smell of formaldehyde or confronting mortality. So we learn to shut off our emotions, keeping the "scientist" mindset. Later, when managing an emergency, we're taught to shut off our emotions and be as objective as we can be. We are told this will serve our patients best.
These are all useful mechanisms, allowing us to do difficult but necessary tasks. The problem is, we become very good at emotional dissociation. It becomes our fall-back state. But this only contributes to our isolation, and it is no help in making healthy relationships. The dissociation that serves us well in the clinic can cause major problems at home. How many times have you made the mistake of being the 'doctor' when you should have been husband, wife, parent or child? When faced with trauma, it is wise to look at the scenario consciously and decide how you need to respond.
Post-Traumatic Stress Disorder
I believe many physicians have PTSD of the complex type. This is a form of PTSD that develops over years. Unlike the other form of PTSD that occurs after isolated trauma, the complex type occurs when events are more subtle but exposure is continuous. Medical training and practice easily fits that bill.
The key symptoms are intrusions, avoidance, and hyper-arousal. Intrusions are a spontaneous thought accompanied by uncomfortable emotions.
How often do you dream of the hospital or school? For most people in training, the answer is very often. Even many years later, physicians still experience these dreams, which are generally not "warm and fuzzy," and may be very unsettling. Other intrusions may occur when you are relaxing or having fun, and suddenly a flash memory occurs about the hospital or school. These can be triggered by a smell, seeing someone that looks like a person you knew in training, almost anything.
Avoidance is the tendency to withdraw socially, when feeling overloaded. It can also be accompanied by self-destructive behaviors, anger, or depression. We are, by nature, social isolates, and this is enhanced when we are overburdened. This is especially true for men, who like to go hide after a rough day. Women, on the other hand, tend to want to talk it out with someone.
Hyper-arousal is the tendency to jump when startled, usually associated with stimuli such as a pager or phone ringing. This is a learned response. When you first got your pager, you were probably excited to be a real doctor! But soon the pager interrupted meals, sleep, and even sex.
You begin to associate the pager with annoyance, setting off a catecholamine response with each page. The mid-brain now interprets the pager as a noxious stimulus. The good news is any learned response can be unlearned. Stress management tools can help you unlearn this response.
The Bottom Line
Many of us lead highly fulfilling lives as physicians and family members, But many others are extremely disillusioned with our careers and our lives. If any of the above personality issues ring true to you and you can see how they adversely affect your life, now is the time to begin to work on them. Show this article to your spouse or friends. Ask them if this describes you, and be ready for the answer. If the answer is yes, don't wait for your relationships or health to crash, seek help early, go to counseling or a workshop. Apply some preventive medicine to your own life!
This essay is extracted and adapted from the forthcoming book "Finding Balance in a Medical Life." Dr. Lipsenthal leads workshops, seminars and lectures for physicians and their families on the subject of personal wellbeing, life balance, and performance enhancement. The Finding Balance Program can help physicians and their loved ones survive transition, manage stress, enhance performance, gain "emotional intelligence," understand and modify personality traits, deepen interpersonal connections, refine communication skills, develop intuition, strengthen personal relationships, manage errors and plan for the future. Dr. Lipsenthal's next seminar will be on October 15, before the American Board of Holistic Medicine's annual review course and exam in Austin, Tex. For more information, please contact Larry Cooper at Health Classics, 800-769-0638 or 805-898-0089 or visit www.healthclassics.com.