DOCTORS AND THEIR FAMILIES

Is there a doctor in the house?*

SARAH B. NELSON, md Family Practitioner, Phoenix, Arizona

ARE doctors' families really different? I think they are. Q: "Who comes first, the patients?" -*** The questions I will attempt to answer are: does having Elizabeth (aged 10): "Yes, the patients ... all our family wasn't well . . . Dad went to work same a doctor in the house make a qualitative difference to the feeling anyway, with Mom ... then they came home weak as they were ... children living there, how are doctors' families different but they lasted through the day". from other busy committed families, and what specific Doctors' problems are inherent in living with a doctor-parent? Of spouses naturally feel guilty competing with sick and When cannot course, individual doctors and their progeny are unique and dying patients. they express their interestingly unalike. Yet, I believe we do have common anger directly, they may take it out on the children. A threads in the tapestries of our lives. neglected and angry spouse finds it difficult to be a good parent. The parenting problems of the medical doctor can be further differentiated from Aim those of other hard working professionals such as lawyers or teachers. The doctor's hours are not are My special interest in doctors' families developed as a sequel only long, but also often to a paper on medical marriages which I presented at the erratic and unpredictable: WONCA meeting in Switzerland in 1978 (Nelson, 1978). Q: "How does that affect your family life?" While the literature contains increasingly revealing reports Marcia (aged 16): "There's a lot of things we can't do about doctors' divorce rates, addic- . . . we don't have that many vacations . . . he always marriages, alcoholism, has to be there for his tions and suicides, there is very little specifically written patients." about the family in general or the children in particular. I The telephone and the bleeper are interruptive and have gathered my material from 13 years in family practice, demanding. All this can lead to an emotional tug-of-war from 9 years in psychiatry, from the shared experiences of between patients and family with the doctor caught in colleagues, and from many interviews with doctors' chil¬ the middle. One woman paediatrician (Heines, 1980) dren. Further, I have learned a lot from my own three expressed such feelings to me when she talked about her children, who had two doctor-parents.a kind of double "bilateral highway guilt". She explained that she used jeopardy family. If, then, what is presented here seems more to feel guilty driving away from her own children in the idiosyncratic or parochial than universal or scientific, I hope morning, and then again felt guilty leaving her child- it will be accepted as an attempt to stimulate thinking about patients at the hospital as she drove home in the doctors' families, especially from the perspective of the evening. children. What, then, can be the consequences of this seeming- ly insoluble dilemma between dedication to profession Workaholic, a culturally approved role and allegiance to family? A lot depends upon how much attention is given to the needs of all family members for Medicine is unique in its special status, dealing with life and love and understanding. A busy doctor usually gets death. Medicine is also unique in the permission societygives plenty of emotional support and appreciation from the doctor to be a workaholic. How can the doctor's spouse colleagues, staff and patients. That same doctor may be or children complain when the doctor in the family is out getting little from a spouse and children who resent his saving lives? He or she is, after all, performing the culturally or her lack of involvement with them. Everyone in the approved role of serving humanity. The family must of family.doctor, spouse and children^reciprocally necessity, at times, take second place:** reacting to each other, can come to feel unappreciated, unloved, misunderstood and neglected. ?Paper given at the WONCA/AAFP World Conference on Family Medicine, New Orleans, 1980. Family therapists teach that the family is an inter- **Quotations are from transcripts of videotaped interviews with doctors* actional system. Nathan Ackerman (1966), who was a children. leading family therapist, has made a provocative state- © Journal ofthe Royal College of General Practitioners, 1981, 31, ment about troubled doctors' families. He said: "The 715-722. doctors who get detached emotionally from their fam- Journal of the Royal College of General Practitioners, December 1981 715 Doctors and their Families ilies are those who aren't getting their backs rubbed in Q: "Is it hard for him?" the right way at home. If they did, I believe they'd Marcia: "It's a 24-hour job . . . he gets tired and works return in kind." Ackerman also said: "The wife who long hours . . . he gets called anytime." doesn't recharge her husband isn't going to get much Q: "How do you feel about that for your dad?" Marcia: "I him for on to it. . . for from him and neither are the kids." Thus this expert envy hanging being able to handle it . . . but I wouldn't want it." made the point that all members of the family have a responsibility to ask for and get what they need, and to He or she may not be communicating to their own give to the others the nurture they need. family. He or she may not in fact be providing a In his or her caring or mothering role, a doctor is prototype for their children: that taking care of yourself comfortable taking care of and taking charge of every- is as important as taking care of others, or that sex is an one else, giving others all the answers. This type of important part of a satisfying life, or that the world is professional behaviour, however, can interfere with an interesting place in which to live and play, as well as parenting children, who also need an attentive listener to work. As he or she achieves one step after another in and approval for their growing autonomy. Too many a medical career, finishing first medical school, then doctors neglect, do not know how or are afraid to shed internship, residency, specialty boards and, finally, the their professional role when they come home to their establishment of a practice, a doctor can become so families. How often psychiatrists hear doctors' children driven to keep climbing one mountain after another, say: "My dad (or mum) lectures instead of listens." that he or she may miss the beauty of life along the way. These competent doctors may really be very lonely Round the age of 35 there is usually a plateau for these people whose own unmet dependency needs are being driven achievers. It is here that divorce or other self- repressed. It is not often recognized that, although the destructive behaviours become a hazard to the family. It medical social world can be stimulating and challenging, is also here that there is a chance for growth instead of it can also be lacking in real emotional depth or failure. A doctor can now replace climbing mountains intimacy. So, it is as important for the doctor's family with living life well. Now is the time when a liberal arts to give lovingly their personal acceptance and under- education and diverse non-medical interests can sustain standing to him or her as a human being, as it is for the and enhance life. family to ask for the same in return. The doctor's children need to know that are they just The halo effect as important to their parents as their dad's or mum's work, even though society puts the doctor on a pedestal. One of the other subjects commonly up like believe brought by Children, patients, they deserve undivided doctors' children is money. This is a problem area attention to their Doctors' problems. spouses often try shared, of course, by other children with successful or to the children or out of to keep quiet sight, ostensibly famous parents. The children recognize that they are save a tired doctor from more turmoil. Another reason economically well provided for. They know the good be that some could the spouse, too, needs time and things money can buy, such as homes, cars, boats, attention. It should also be recognized that, when clothes, vacations and education. They resent, however, and too problems demands of family become much, the one common statement made by other children on doctor may escape by finding a patient who just must be learning that their father or mother is a doctor. Kids seen, or charts which must be completed. Doctors' work say, "Oh, you must be rich!" Doctors' children fight is a convenient and worthy excuse to avoid family against this assumption as though it were not true. What responsibilities and intimacy. The office can be a safe, they really resent has been termed the 'halo effect', that but rather sterile, haven: is the special status accorded to members of a doctor's Q: "Can you characterize your father in just a few family. Kids do not want to be stereotyped by their words?" parents' wealth any more than doctors' spouses today Carol (aged 28): "I can do it in one word.missing, for want to be known as 'Mr or Mrs Dr' instead of for their the most part." own traits and talents. It is an identity issue for both children and spouses: An outer-directed life Ann (aged 21): "When I tell people my father is a Returning to other specific effects on the children who doctor . . . sometimes that's good and sometimes that's bad ... I want to be not the of the live in a doctor's house, what is the philosophical Ann, daughter doctor . . . somebody that knows what to do and that's message given by this workaholic, but culturally ap¬ me that knows it." proved parent, whose family must often come second? He or she lives an outer-directed life, respected by and Another money-related issue is the use of money and the dedicated to others: material objects it can buy as a substitute for a parent's time and involvement with the children. The Talking about father's job: doctor, who often quite genuinely feels short-changed and even Marcia: "It's like something he has to do . . . he has to wistful about his lack of time for interaction with his be there for his patients ... they pretty much expect him to be." children, may try to make up for this deprivation by 716 Journal of the Royal College of General Practitioners, December 1981 Doctors and their Families spending money on himself or his family. Or he may be dren are themselves patients, it is not surprising that motivated by the children's anger and his own guilt and they may sometimes worry about being taken lightly or try to mollify these feelings with material goods. Ir being ridiculed, or that their confidences may be dis- certain situations this use of money can lead to material- closed to the other doctor's children: ism or feelings of rejection, or even a chronic sense of Carol: "When I was 13 ... I was not doing well in or abandonment in some children. emptiness school. . . my parents sent me to a psychiatrist. . . after going to her for a short time ... I believed that, because my mother was a doctor, this woman doctor was telling 'Less than optimal' medical care my confidences to my mother ... I stopped telling the doctor anything ... I would play the games and talk One of the seemingly paradoxical but nevertheless very about all sorts of fictitious things, but I would never tell real problems common to doctors' families is their her anything that was important to me." difficulty in getting good medical care.or, as it is often understated, doctors and their families receive 'less than The curse of medicine optimal medical care'. There are a variety of reasons for In to this less-than- this. First, a doctor is under a tacit pressure to deny addition confidentiality conflicts, care the personal illness. This comes both from society and from optimal medical is compounded further by his or her own internal need to succeed and to be doctor's training. Doctors learn to react to their daily and perfect. Psychiatric illness, addiction or family prob¬ experiences of pain, suffering dying by erecting lems are often the most difficult for him or her to admit. barriers to spontaneous feelings. Doctors are taught by at Asking for help for these human conditions may be seen experience to become hardened to human misery, and as an admission of failure, weakness or poor perfor- least enough to allow for objective detachment mance. Once a doctor does decide to seek outside rational functioning. What is the outcome of this de- medical help for, let us say, one of his or her children, fence against distress in the context of family? It has of medicine' he or she may go about it in inadequate or improper been called the 'curse (Zell, personal can be ways. There may be cocktail party consultations, or he communication, 1980). A variety of reactions are to either or she may consult too close a friend or insist unwisely seen, but doctors well known overrespond on seeing no-one but the head of the department. He or or to ignore their own or their families' physical or she may be demanding or too collaborative to the point emotional distress. This is what the children grow up of interfering. He or she may be defensive and secretive with. How often have we all heard a variation of the about possibly embarrassing but pertinent personal joke, "Take two aspirins and call me in the morning"? details. Although a doctor may feel omnipotently How often have we dismissed our own families' real a The next is exempt from human frailties on the one hand, he or she medical needs in similar fashion? question answer has our detach¬ may also delay proper care because of self-doubts and harder to truthfully. How often us our children's emotional fears of his or her own dependency needs. This all ment protected from pains? comes out as the excuse of not wanting to impose on or And at what expense? in a doctor's home are also often more inconvenience the other doctor. That professional cour- The children tesy compounds this problem should by now be well exposed than other children to death and, more signifi- known. Then, there may be further impediments to cantly, to the responsibility for life or death. A sensitive good and objective medical care caused by the treating child may become very disturbed by awareness of a doctor: he or she may have a tendency to overidentify doctor-parent's sense of failure and depression over a with the doctor-patient and his or her family, resulting patient's death. Shockingly, some of these children in under- or overdiagnosis and treatment. The treating come to psychiatrists with a grossly distorted sense of doctor may feel intimidated and inadequate and become reality. They have developed psychotic perceptions of defensive or approval-seeking. He or she may court their doctor-parent as a God-like rescuer or a vengeful, favour in order to get referrals. The parent-doctor may mutilating power. be unwisely allowed to be overinvolved in the treatment plan. Doctor-patients are undeniably different due to The of medicine college and social connections. mystique Confidentiality problems also can arise. We teach our Yes, it is true, we are unique among the professions in children well about how we value confidentiality, our privileges. We are licensed and trusted to invade though our children do hear us talking about patients in with our hands and our instruments the most private the privacy of our own homes. Even though we may be and sensitive areas of the body and the mind. We are careful not to mention names, our children hear us privileged to look at the human body in ways denied by crack jokes about crocks and amuse others with funny society to any others. We examine the nude body, take stories about patients. We may well be defending our- x-rays and EEGs to discover what even the patient selves against our own painful emotions of the day; cannot see or know about himself. We are also privi¬ after all, humour is an appropriate and mature outlet leged to prod and poke into any bodily orifice, as well as for accumulated tensions. Nevertheless, when our chil¬ to surgically cut, giving us a potentially powerful and Journal of the Royal College of General Practitioners, December 1981 717 Doctors and their Families dangerous role. We are the top level of professional help Expectations available to helpless and vulnerable patients. We, alone, deal actively with death. This has been called 'the Now what about the expectations in a medical family? mystique of medicine' (Zell, personal communication, Doctors are under pressures from themselves and from 1980). society for excellence, in all areas. Patients seem to miracles. looms as a threat to What does all this mean to our families? One rather expect Malpractice status, self-esteem and Inflation a sense of universal answer was a doctor's son re- solvency. may bring expressed by failure and values in to a declaration: "Your Dad saved depression. Changing society may sponding patient's make the doctor who is dominated the work ethic my life" with the statement: "It makes me feel good by feel out of touch with the and his inside." Others say: "I feel proud" or "It's neat." younger generation or her own some of whom seem to have They usually see their doctor-parent as a caring, dedi- children, cated, respected member of their community. adopted an ethic of 'if it feels good, do it'. Actually, offers our children more and different But what else do our children see? Have you ever society today choices than we had in the when was more wondered what children are doing when they 'play days society structured. We need to face the fact that not all our doctor'? The sexual overtones of 'playing doctor' are children will become or Indian chiefs. How does that relate to a child's doctors, lawyers unquestioned. percep- become but not doctors. to tion of the doctor-parent's role? This connection can be They may healers, Contrary our own education not confusing to a child's sexual development. The doctor experience, graduate-level may be relevant or for some of them. who has such knowledge about the human body must be important In view of all what do we have for an expert and a good example in regard to sexual this, expectations our we want them to be matters, or so it would be natural for a child to assume! children? Certainly happy, In fact doctors have been poorly educated about sexual- healthy individuals, but we are, nevertheless, often most of their scholastic successes and most disturbed ity, and may be more embarrassed than other parents proud dealing with these issues: by academic failure. Our children tell us how they see it by their behaviour. When they are unhappy or feeling Q: "Did your parent teach you adequately about sex?" they rebel by becoming underachievers in Carol: "I did get a talk about hamsters and mice one pressured, school. Doctors, who live a disciplined, structured life, time when I was quite young . . . we had some prolific are embarrassed and offended children who little animals ... then there were a set of books . . . by appear which would just appear on my bed at the appropriate lazy and unproductive. But a doctor-parent is in many times, one was entitled The Doctor Talks to 9 to 11 Year ways a hard act to follow. Children need approval and and later there A Doctor Talks to Olds, appeared time to find their own personalities, likes and talents. 13 to 15 Year Olds... but the doctor never really had a talk." Some doctors' children solve this dilemma by choosing a career one boy called "different but equal". Doctor's They may not listen well to their children, but may tend children usually do admire their parents' community to preach or lecture when feeling defensive because they image and dedication, but, if kids see that a doctor's do not know all the answers. The more expressive and reward for being a doctor is to be late, spend a lot of feeling aspects of sexuality may not flow freely from a time on the phone, miss family life and be irritable, it is performance-oriented doctor-person. A Presbyterian no wonder lots of our kids get turned off from medicine minister (Charlie Shedd) wrote in his book Celebration as a career. They may want more than this for them¬ in the Bedroom: "We want our children to know that selves and their future families. We should be glad if sex is beautiful and that there are good things going on they do. between mom and dad." How many of us let our children know that marital sex is a joyful, sharing, Conclusion valued part of our own lives? Confusions may also result particularly, and some¬ In conclusion, how can we use what we now know about times destructively, if the doctor's child is subjected to the problems our children may face living in a doctor's medical treatment by his own respected, and seemingly family? We can start by striving to live a balanced life. omnipotent, doctor-parent. Children can be trauma- We can perform a life of service to others, but tempered tized by such unconsidered actions as a parent giving his by compassion for ourselves. A balanced life includes or her child anaesthesia, or performing a circumcision. attention to love and play and to our own health needs, A child can feel exposed, violated or punished. Psychia- as well as attention to our patients and our work. We trists working with such children find that unusually can use our compulsiveness constructively to achieve sensitive children can have very frightening fantasies, whatever we want or need. We can build a good family sometimes of psychotic proportions, about castrating or support system to include more open sharing of our¬ all-powerful doctor-parents. The warning here is that it selves as real people. We can use our history-taking is particularly important to avoid confusion in roles skills to really listen to our loved ones. We can give time between that of doctor and that of parent. Doctors and attention to ourselves and our families, while at the should not succumb to the temptation to treat their own same time showing our patients how to live a well- children. balanced life.by scheduling and explaining our own 720 Journal of the Royal College of General Practitioners, December 1981 Doctors and their Families

need for time away from our medical work. The same Mattson, A. & Derdeyn, A. (1977). The child psychiatrist treating talent for detachment from family when listening to physicians' families. Journal of Child Psychiatry, 16, 728-738. Meighan, S. S. & Osborne, (1978). Adored at the office-abhorred patients can be used to detach from patients when it is at home. Impact, 22 Sept. time for family. We can use our money to expose our Menninger, W. C. (n.d.). Marriage and Mental Health. 2nd. children to the world, to the excitement of new Philadelphia Marriage Council Award: Acceptance Speech. places, Philadelphia: Evening Bulletin. people, activities, ideas, thus teaching them flexibility in Nelson, S. B. (1978). Some dynamics of medical marriages. Journal a rapidly changing world. We can teach them to be of the Royal College of General Practitioners, 28, 585-586. comfortable with Physician's wife tells a happy story. American Medical News, 13 themselves, whoever, whatever and July 1979. wherever they are, by revealing our own humanity. We Robinson, D. 0. (1978). The medical-student spouse syndrome: can teach our children by our acceptance of ourselves grief reactions to the clinical years. American Journal of with all our traits, whatever they may be-perfection- Psychiatry, 135, 972-974. Wallinga, J. V. (1974). The children of physicians. Medical Times, ism, compulsiveness, dependency needs, weaknesses 102, 115-126. and all. We can use our own capacity for affection and Wittenberg, C. (1979). Psychiatrists discuss their parenting skills. understanding for our patients, for our families and for Psychiatric News, 3 August. Wolf, T. M. (1980). The world's lousiest patients? They're doctors. ourselves. For only by loving ourselves well can we help Medical Economics, 12 May. our children to develop into the loving, confident, productive and beautiful human beings they were born Address for reprints to be. Dr S. B. Nelson, 3352 East Camelback Road, Suite E, Phoenix, Arizona 85018, USA.

References and further reading Ackerman, N. W. (1966). Experts view the doctor as a family man. Medical Economics, 22 October. After hours. Medical Economics, June 1979 (entire issue). Altered marital lifestyles affect medical practice. Family Practice News, I Sept 1979. Charlton, R. (1980). Divorce as a psychological experience. Psychiatric Annals, 10, April. Deredyn, A. (1980). Divorce and children: clinical interventions. Psychiatric Annals, 10, April. Donahue show gets spirited defense of medical marriages. American Medical News, 13 July 1979. Cimetidine and liver blood flow Experts view the doctor as a family man. Medical Economics, 17 Oct 1966. The influence of cimetidine on liver blood flow was Experts view the doctor as a father. Medical Economics, 14 Nov 1966. studied in eight normal subjects. Cimetidine actually Experts view the doctor as a husband. Medical Economics, 31 Oct reduced liver blood flow during fasting by almost 25 per 1966. cent, and chronic cimetidine therapy (300 mg qds for Flach, F. (1980). Divorce and the psychiatrist. Psychiatric Annals, 10, April. seven days) reduced the flow by 33 per cent. Cimetidine Garvey, M. J. (1980). Stability of physicians' marriages. Medical also inhibited the metabolism of oral propranolol and Aspects of Human Sexuality, April. thereby further reduced elimination; this effect is prob- Garvey, M. & Tuason, V. B. (1979). Physician marriages. Journal of Clinical Psychiatry, 40, 129-131. ably dose related. Gillespie, H. & LaPointe, C. (n.d.). Physicians' marriages in crisis: sex and-love at midlife. Sexual Medicine Today. Source: Feely, J., Wilkinson, G. & Wood, A. (1981). Reduction of Goldney, R., Czechowicz, M., Dibden, S. et al. (1979). The liver blood flow and propranolol metabolism by cimetidine. New psychiatrist's family-a comparative study. Australian and New EnglandJournal ofMedicine, 304, 692-695. Zealand Journal of Psychiatry, 13, 341-347. Growing up in the 50s and the 80s. The Arizona Republic, 23 Jan 1980. Hales, D. (1980). The family: coping with a changing world. Facets, winter. Heines, M. (1980). Remarks made during presentation of 'Changes Words our patients use in society and their effects on physicians and their families'. Meeting of the Arizona Medical Association, Phoenix, 'Moither' or 'mither'-to confuse, perplex or worry Arizona, April. (reported by a reader from Worcestershire, but de- Johnson, C. (1979). The American family during inflationary times. scribed in the OED as a dialect word from Psychiatric Opinion, Sept. Cheshire, Kales, J., Martin, E. & Soldatos, C. (n.d.). Office counselling: Derbyshire, Herefordshire and Gloucestershire). emotional problems of physicians and their families. 'Hirpling'-limping with pain (Glasgow). Pennsylvania Medicine, 81, No. 12. "To chunter"-to be cross or with McCaffrey, J. C. (1978). Do doctors have to be poor patients? irritable, usually Behavioural Medicine, June. reference to a baby (Glasgow). MacIntyre, A. (1967). Seven traits for the future. In Reflections on 'Greeting'-crying (Glasgow). Research and the Future of Medicine, and Other Addresses. 'Wallies'-false teeth (Glasgow). Ed. Lyght, C. E. New York: McG3raw-Hill. Martin, P. (1979). Dynamics of family interactions. Journal of "He's got his arm busted"-he has an injury, not Continuing Education in Psychiatry, Jan. necessarily a fracture (Glasgow). 722 Journal of the Royal College of General Practitioners, December 1981