Focus
Student Scene
April 9, 2001
 Tarayn Grizzard Photo by Jeff Cleary |
Love in the Time of Medical School
Birds do it; bees do it; and occasionally, over-educated and sleep-deprived medical students manage to do it. At some point in every medical student's career, love happens. Whether it's the "forever" touted by DeBeers commercials or a momentary lapse of sanity, relationships in medical school, despite unforgiving circumstances (like surgery clerkship), do happen.
The outcome of these relationships seems, at best, unpredictable: while many medical students are married, or become married in the course of medical school, these marriages do not have an exceptionally good prognosis. The chance of any first-time marriage lasting is about fiftyÐfifty. But one might think that the privileged status that medicine confers would shield physicians from some of the forces that wear down the bonds between spouses. Unfortunately, medicine also brings with it its own set of stressors.
In some medical specialties—psychiatry, for example—divorce rates stand at about 50 percent (from The New England Journal of Medicine as quoted in White Coat by alum Ellen Rothman). Given the strenuous schedules of doctors-in-training, years of financial woes that sometimes follow medical education, and the stress inherent in caring for patients, the statistics aren't surprising in the least. However, it is ironic that physicians, who are skilled in observing physical and psychosocial clues in others, are often unable to recognize symptoms of strain in their own personal relationships, and are unable to resuscitate their marriages.
Tell Me Where It Hurts
Though divorce rates for physicians aren't higher than the national average, it's still disturbing to find that profession alone is an independent risk factor, rather than typical risk factors such as marriage prior to age 18. The fact that a profession itself seems to be a risk factor is, to put it mildly, a problem.
The real question is, what puts medical marriages at risk? Physicians in training are subjected to stressors like financial burdens, long hours, and emotional strain, but so are many other professions. There is no real profession-associated problem with divorce in the military, for example, where the stresses of combat training, low pay, and on-duty time are arguably equal to, if not more than those of medical students and residents. I grew up in an Air Force family, so I've observed these dynamics firsthand. In fact, the strength of military families is often a selling point for the armed forces, a way to uphold the traditional way of American life to inspire patriotism and (hopefully) enlistment.
The military has a very strong internal culture, replete with rituals, language, and symbols all its own, much like the medical culture; and both discourage, by the very rigor of their cultural demands, serious fraternization with other subcultures within our society. The similarities between the lifestyles and demands of medicine and the military are numerous, but the differences in home and family life are remarkable. The question is, what makes medical marriages different from those of other professionals?
Work: The Home Away from Home
One thing that possibly makes medical marriages distinct from marriages of other high-stress professionals—and perhaps distinctly at-risk as well—is the difference in the idea of home. As Arlie Hochschild argues in her work The Time Bind: When Work Becomes Home and Home Becomes Work, the idea of home is rapidly changing in American culture. Home is no longer the safe haven of 1950s TV shows, but rather a noisy interlude filled with screaming toddlers and young children, a bitter and feuding spouse, bills to pay, a home to take care of, and no reward or end in sight.
Work, on the other hand, has become the American haven from home life. The workplace has social gatherings, incentives for working harder, and, most important of all, a salary, a palpable measure of one's worth. Supervisors may overwork their employees, but the employees are compensated with overtime, bonuses, and, often, genuine appreciation on the part of the supervisor. Most importantly, however, the work world is a comfortable, albeit demanding, place for many people, and one in which they were comfortable prior to entering marriage.
The expectations of the workplace are set, and many employees are socialized into the work setting by various standardized methods of training and promotion that organizations set up as a way of maintaining the corporate culture. But there is no set way to standardize one's home life, and in an increasingly money-driven culture, there isn't as much incentive to do so since the demands of work financially overshadow what needs to be done at home.
For physicians-in-training, this schism between home and work is especially sharp. Shifting the center of one's life from home to work—work being the place where one primarily lives and grows—is a professional necessity for physicians-in-training. The hospital literally becomes home for many medical students when they're "on the wards," and residents—as the title itself implies—may spend the vast majority of their work week and even their sleeping hours at the hospital and the on-call room. This schedule can persist for years, especially for the more demanding medical specialties. When the physician returns to a more normal lifestyle, with more hours at home, problems frequently erupt.
Many physicians may feel more comfortable at work, in the hospital culture where they worked prior to marriage and family commitments. Home seems like a burden, a game with shifting rules and expectations that may seem to change day-to-day. Spouses may feel abandoned by the years of long hours and the seeming lack of desire of the spouse to "return" to the home. This is especially a problem for spouses who are not a part of the medical field themselves, who don't understand why the hospital is so important in their significant other's life. Many couples, however, who are both in the profession, may also suffer as they both establish the hospital as home instead of forming their own distinct marriage culture.
A Military Solution
The negative consequences of this situation isn't seen in the Armed Forces to nearly the degree it's seen in medicine, and the differences between these groups may help elucidate some possible solutions for the problems of the medical home. In the military, effort is made to include the family in the military culture. There are Officer Wives' Clubs, family-centered sporting teams for the different regiments and divisions on the military base, along with basewide activities that bring the soldier and his or her family into the base and military culture. Most bases have a home and family division that sponsors these activities, holds counseling groups and retreats for couples, and generally provides support for families. These events and the support that comes with them are in place even when troops have been deployed or when it's time for submarine duty. Most importantly, however, military families live together, typically on the military base, in close proximity to the culture that is placing demands on one of its primary members.
Rather than being isolated from the family culture by working for the military, the military culture seeks to become a part of the family culture. And although military families have problems, and certainly have a divorce phenomenon of their own, there doesn't seem to be the association between the military profession and divorce like there is in the medical profession.
The efforts of the military to maintain family life in the face of rigorous family demands cannot be underestimated. How different would hospitals be if they offered a strong, proactive work and family office for residents and their spouses and children. Many hospitals have similar divisions, but very few are diversified or funded enough to offer more than the yearly hospital picnic for residents and their families. Many residents and families could use more than the yearly or quarterly nod to their true home lives. Given the stresses of the job, many residents and their spouses could certainly appreciate access to inexpensive, excellent marital counselors like those offered to military spouses. Subsidized daycare is often available on-site at hospitals, but why not be more proactive and promote activities for kids and parents at the hospital, or offer inexpensive tickets to the zoo, the science museum, or other locales to encourage parent–child interaction?
These ideas seem expensive at best, intrusive at worst; however, resident mental health has been a constant concern for attending physicians, deans, and outside observers for many years. The stresses inherent in the profession—patient load, health cost controls, and malpractice premiums—show no sign of lessening in the near future. Helping residents better manage and enjoy their families is one area in which hospitals could actively help. Improving and strengthening family relationships would not only decrease stress but would also provide an improved support network for residents. Given what is required of these medical soldiers, asking hospitals to provide emotional and social support for their families doesn't seem too much to ask.
—Tarayn Grizzard, a first-year medical student at HMS
Hochschild, Arlie R. The Time Bind: When Work Becomes Home and Home Becomes Work, Metropolitan Books: New York, 1997.
Rothman, Ellen Lerner. White Coat: Becoming a Doctor at Harvard Medical School, William Morrow and Company, Inc.: New York, 1999.