Primary care practice can be both an enriching source of personal growth and meaning and an unmerciful and depleting taskmaster. It provides us with access to a broad range of human experience—an intimate view of the characters and stories of a thousand novels—and an opportunity to have our very presence matter to others. At the same time, it makes constant demands and surrounds us with perpetual uncertainty; it relentlessly confronts us with our limitations of time, energy, knowledge, and compassion. It is a job that is never done; at best, problems are stabilized until something else goes wrong.

The balance each of us strikes between our own enrichment and depletion is critical to our own physical, emotional, and spiritual health and to our ability to care for others. All too often, however, we lose sight of this balance. We become so outwardly focused, attending to clinical problem solving, that we do not tend to our own renewal. This lack of balance is not surprising, our education has taught us much more about how to care for others than how to care for ourselves. The socialization processes of medical school and residency have cultivated a variety of unrealistic self-expectations and attitudes, especially concerning control and self- sufficiency.

Over time, this imbalance can produce a vague but increasing sense of demoralization, in which the joy of work is lost and patients seem increasingly annoying and adversarial. Work becomes the means to some other end—skiing trips or a vacation house—rather than meaningful in its own right. When the root causes of this dissatisfaction are invisible to us, we blame external sources such as the government, insurance companies, or lawyers. Although there are many legitimate complaints about restrictions and bureaucracy, the most fundamental determinants of satisfaction and well-being are not external but rather are found within.

In this chapter, we will examine important values, attitudes, and skills that affect our well-being. We will also consider the subtle but powerful effect of our work environment and personal practices that can keep us healthy.

The foundation of our well-being is the acknowledgment that we are human, that we have needs and limits, and that to keep on giving we must know and have reliable access to those things that sustain and revitalize us. Unfortunately, the notion that clinicians have needs has been put off-limits by traditional professional ideals. An excessively narrow interpretation of the scientific model calls on us to be detached and objective observers, leaving no room for our own subjective experience. We are also exposed early, and often, to the ideal of the clinician who is selfless, invulnerable, and omnipotent.

In actuality, each of us has a variety of needs, both universal and neurotic, that cannot fail to assert themselves. Our health and well-being depend upon the degree to which we are aware of and attend to them consciously and purposefully.

Among our most fundamental needs are those for human connection, meaning, and self-transcendence—experiencing ourselves as part of something larger than we are. Clinical work is particularly rich with opportunity for human contact and appreciation. Many studies have shown the patient–clinician relationship to be the single most important factor contributing to physician satisfaction (mirroring its central importance to patients). When we are working under excessive pressure or in situations for which we are not adequately prepared, however, clinical work can interfere with the satisfaction of these needs resulting in depersonalization and alienation from and hostility toward our patients.

Clinical work can also threaten the fulfillment of transpersonal needs through family and community life. Family and career often compete intensely for time and attention, too often to the detriment of the former. Moreover, we sometimes have difficulty shedding the white coat—leaving our professional caretaking role and expressing the spontaneity and vulnerability necessary for intimacy. As tensions build at home, putting more time into work can provide a short-term escape. In the long term, however, avoidance of difficult relationship problems leads to alienation and potentially to the breakdown of crucial personal support systems.

In addition to our universal needs for connection and meaning, we also have very individual neurotic needs—born of pain and conflict—that are intimately related to our medical work. These needs influence both our motivation to go into medicine in the first place and the way we practice. Out of a need to feel loved or appreciated, we often find ourselves in the role of overfunctioning caretakers, and our difficulty saying “no” quickly leads to over commitment. Feelings of impotence engendered by childhood experiences of illness—our own or those of a close friend or relative—may be relieved through our work with patients, but the wishful fantasy of controlling disease is constantly challenged by reality. Voyeuristic desires, fear of death, and the fulfillment of parental expectations are other factors, conscious or unconscious, that can motivate our careers.

These darker, neurotic needs are no less legitimate than those less hidden; they, too, are a normal part of life. When these needs operate outside our awareness, however, they can drive us to work excessively, assume unrealistic degrees of responsibility, and otherwise distort our work lives, thereby causing us to suffer. If we invest ourselves in unrealistic solutions that must inevitably fail, we risk chronic anxiety, substance abuse, and even suicide. Through various processes of self-exploration (such as psychotherapy, peer support groups, or mindfulness workshops) we can become more aware of these needs that underlie our work and find healthier ways to satisfy them. We ignore them at our own peril.

Another important but under-recognized determinant of our well-being is our personal philosophy—the deeply held beliefs and values that address the most fundamental questions of our lives: the meaning and purpose of life, death, joy, and suffering; why things happen the way they do; the nature of our relationship to other people and to the world; and the nature of our goals and responsibilities as human beings. Our personal philosophies define our expectations of ourselves and other people. They guide the way we perceive and respond to our world and help us identify our place in it. They define the framework by which we imbue things in our lives with meaning, joy, or pain and by which we determine what seems right and what seems wrong.

Developing a personal philosophy tends to be a subliminal process—a gradual internalization of attitudes and values from family, culture, education, and life experience. This process makes it possible for us to be entirely unaware of our core beliefs as an ideology; we may take them so completely for granted that they just seem to be part of the way things are. If we do not understand how these beliefs filter our perceptions and shape our behaviors, then we are unable to subject them to critical reflection and to decide which parts work well for us and which parts need to be changed.

The Control Model

An aspect of personal philosophy with special importance to clinical practice is our attitude toward control. Through the influence of Western culture in general and medical culture in particular, we often perceive being in control (of diseases, patients, and the health care team) to be the ideal state (Table 6-1). We use specific intellectual tools for gathering and applying knowledge: reductionism—

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