Success, Regret, and the Struggle for Balance

Carrese and Ibrahim successfully stimulate their readers to think about how to achieve professional and personal balance in academic medicine. The question is an important one, and not easily answered. I believe it probably takes a lifetime to answer. The question inevitably leads to a larger, more philosophical one- a question at least as old as Socrates: how to live one’s life? We make the best decisions we can at any given time in our lives, with the help of friends, family, mentors, self-knowledge, and the wisdom available to us. We make mistakes. We wrestle with regret. However, if we’re lucky, we come around to the idea that it’s difficult to learn - and to change- things about ourselves and lives without struggle. Like MI, hindsight does not presume we would live our lives differently if we had the chance. Although the author has regrets, he hints that his own life has a richness and depth now that may not have been possible without the life course he chose.

When we are busy writing papers, lecturing, attending soccer games, or seeing patients, we are necessarily not doing something else. Multitasking only takes a person so far. The challenge is to find things in medicine and life we enjoy doing, and also have a talent for; knowing that priorities and goals constantly change, knowing that our boss, spouse, or children may want us to do something else-and knowing that it’s impossible to get our lives exactly the way we want it. What we want now may not be what we want the next day, week, or year. That being said, if we do not reflect on how we want to live our lives, we risk leading a life completely defined and shaped by others.

Of course, it will take more than reflection for faculty to successfully advance up the academic medicine ladder and to lead satisfying lives. What can we hope for? We can hope for a new generation of academic medicine leaders who encourage- and reward- their faculty for being professionally excellent and well rounded- and reflective.

In my opinion, such a faculty will be good for patients, residents, medical students, academic institutions, communities- and business!

Competing interests:   None declared

Two observations from someone with few regrets:

1. To whom is the physician primarily responsible? Possible answers are patients, family, the profession, the community or society at large. I believe we are responsible first to self. It is only when we reflect on our values and beliefs that we can appropriately prioritize our competing demands and then serve those other important people. I thank the authors for stimulating the discussion: perhaps a few folks paused in their busy schedules to do the important work of reflection.

2. My experience is summarized by a line from a John Cougar Mellencamp song: "I know there's a balance. I see it when I swing past." I haven't gotten it quite right, but I do keep trying.

Competing interests:   None declared

The work-first vs. family-first dilemna does not strike at the heart of the matter in my opinion. The tougher balance to strike is the me-first vs. others-first divide. Walking this tightrope well, helps us all across the gender divide and through the generation gap.

For full disclosure, if I have faltered on either side of the work/family divide, I would be labeled the workaholic over the family-centered person. My regrets go more easily to remembering the pain of being on OB call and telling my four cute kids that I couldn't go to the beach with them, because a patient needed me. I doubt they believed my story fully that their dad just loved taking them to the beach on Saturday and having them all to himself.

However, in my opinion, the balance that is more important to strike for happiness/contentment/wellbeing is the balance between "doing for others" and "doing for self". Discontent and poor health can enter our lives more commonly from imbalance here, than any other disequilibrium I know.

I know I have fallen off on the "doing for others" side of the divide, when I start feeling "Stop your sucking, my tits just aren't that big!". It can happen either with respect to work, or with family. We can go all out for others at work and end up depleted and worn out, or we can give and give to our families and end up with selfish brats and spouses on our hands. In contrast, with the "doing for others" impulse in balance, we can get a lot of meaning from our devotion to patients, colleagues, and our sacrifices for a mission we love, and we can honor our families with the time and attention they need and that ironically feeds us.

Falling off the "doing for self" side of the divide,we might shirk our responsibilities to our colleagues, our institutions, and society in a "me and my family first" orientation. Likewise, we can go astray in living through our families, controlling or smothering our kids in the name of "me, the perfect parent". In contrast, with the "doing for self" impulse in balance, we can pursue work for creative self-actualization, and take time for fun and exercise and family life, thereby expanding our selves through intimacy and generativity.

It's all about me AND others. I need to know that I am in a job for me and for others. I also need to remember that I am in a family for me and for others. This is the balance that we strive for.

Competing interests:   None declared

Thank you Drs. Carrese and Ibrahim for the generous reflections you have shared in "Success, Regret and the Struggle for Balance. I am a female faculty member somewhere between you in my career. The need for multiple pathways to academic inquiry and products is clearly demonstrated in your comments.

So what do I expect. Hmmmm - I chose family medicine as a career because the rewards in the relationships in my every day life are what get me up each day: be they with family members, patients, students, residents and colleagues and co-workers. I expect those relationships to fuel me and they do. The feedback I get from those on the other side would indicate they share the benefit most of the time. I have been blessed to be in great teams. It is not a bad place to be after raising four children, surviving a spouse's horrendous illness, treating thousands of patients, graduating over 250 residents, developing several fellowships and doubling a faculty and clinical capacity for patients.

Oh yes, we have piles of data unpublished, continuing research and inquiry that may never reach an editor's desk, and they remain low on my priority list because they just don't juice me like those relationships do. But, life is long and I still have time - something our ancient role models in the 1930's did not. It is good to be a woman in medicine with a few years ahead of me. It is good to work in teams because we support each other. We should all live longer so maybe we shouldn't expect to be professors until we are 80.

Competing interests:   None declared

I was intrigued by Drs Carrese and Ibrahim's article. As a Gen-Xer, my physician friends and I have constant discussions about ways to balance work and home. Sadly, the answer for most of them has been to leave academic medicine with the idea to return "someday when the kids are grown". When I was Residency Director of a large 30 resident program I delivered my second child and made the difficult decision to go "part-time". I worked 4 days a week, took full call, including OB and inpatient. I made 85% of my salary, but worked the same number of hours. My friends in private practice called me crazy, pointing out that in private practice, full time work weeks are usually 4 days, especially for physicians taking call.

My hope is that academic medicine will catch up with what is needed by up and coming physicians. My generation and the next is unwilling to sacrifice our families, our health and our personal lives for our jobs. We need to change our thinking about how things need to be done or we will continue to lose fine physicians.

Competing interests:   None declared

The conversation between Carrese and Ibrahim reminded me of the inner struggle I experienced for years as "Father" David wrestled with "Doctor" David. Eventually, I came to realize that there was no need for such tumult. Balance is a matter of focus. Once I accepted that, as a single parent, my daughters HAD to be the focus of my life, the rest was easy. Fortunately, even if the institution didn't understand that perspective, my colleagues with their family medicine "gestalt" had no difficulty in comprehending why I resisted weekend clinic responsibilities and limited travel to conferences. In addition, I believe that a strong family life spills over into our clinical care; we are better family physicians if our home lives are in focus.

But such focus can also drive professional productivity if you apply the same focus to your own career planning, learning efficiency in your academic foles. Plan your career. Avoid distractions. Pursue your passions.

Competing interests:   None declared

I applaud Drs. Carrese and Ibrahim for their article: “Success, Regret, and the Struggle for Balance.” Dr. Ibrahim shares his candid, heartfelt experiences and reflections on the challenges he faced and difficult choices he made throughout his professional life. His perspective is refreshing, insightful and painfully honest. I commend him for bringing a voice to a sentiment that is not well-represented by his demographic. While Dr. Ibrahim clearly expresses some of his regret, he demonstrates that he has learned from his past decisions, and has embraced a newer, more well-balanced mentality. This is noticeable in his willingness to simply engage in conversation about balance with his own, younger mid-career physician Dr. Carrese. Both physicians have accepted and recognized the possibility for success within the “newer” paradigm of personal-professional balance in medicine. Each has defined success differently, and their comments help exemplify that while we often want it “all,” we must recognize that we can’t always have it “all,” or not “all” of it at the same time in our lives.

It is no surprise that work-life balance has a great impact in medicine career choice. In order to continue to promote students to pursue any medical specialty they most desire (including primary care), more senior leaders in medicine must recognize and support the changing career needs of our faculty. The members of our faculties are our learners’ role models, and as Dr. Ibrahim clearly recalls, his own mentors did not exemplify balance. This is particularly important in academic health centers (AHC), where the future supply of our next generation of educators and leaders will be Generation X’ers. The administrative leaders, most from previous generations, have been slow to examine and address differences and real tensions between the generations.1

The authors, in their willingness to reflect on their own experiences, poignantly challenge other senior leaders to help affect change. While the more seasoned faculty of many institutions may or may not have similar regrets, those who do have a chance to positively impact future generations. It is my hope that Drs. Ibrahim and Caresse can actively continue to share their insight and expertise with both their colleagues and protégés, and help propagate their sentiments. We must embrace current efforts underway to promote flexibility in career trajectories including support for part-time work options, slowing of tenure clocks, and changing eligibility for research funding to include less than full-time options. We want to remain committed to enhancing the work lives or our students, trainees and faculty, so they may balance personal and professional endeavors, without compromising excellence in medical practice, education and scholarship.

1. Bickel J, Brown A. Generation X: Implications for faculty recruitment and development in academic health centers. Acad Med. 2005;80:205-210.

Competing interests:   None declared

I read Joseph A. Carrese and Michel A. Ibrahim's article: "Success, Regret, and the Struggle for Balance" with compassion and hope. Dr. Ibrahim has shown great courage and has offered us hope for a different work-life standard by writing about his experiences, feelings and reflections on the importance of values-driven life choices. It is encouraging to learn how positively insightful he is about the generational differences between medicine faculty of his generation and the current generation of trainees. Dr. Ibrahim wistfully relates to the personal rewards that Joe, his personal physician, enjoys because of his decisions to delay career advancement to be more present to family members. He recognizes that Joe has made different choices than he did and he demonstrates great respect for those choices, to the point that he questions the wisdom of his own past career-life decisions. This ability to truly understand both sides of such decisions is what we need in leaders of academic medicine. Dr. Ibrahim is at the top of the academic ladder and sees a better way! He seems to regret some of the outcomes of his past decisions, recognizes the hope in the current generation and is in a perfect position to initiate changes in academic medicine that will promote the acceptance of less than full-time work options for the current students and trainees of medicine. He has my support and I hope the younger generation identifies him as a mentor in work-life balance who has much wisdom to offer.

Competing interests:   None declared

I appreciated the essay by Dr.'s Carrese and Ibrahim. As a 50 year old associate professor, I especially resonated with Dr. Carrese's concern that he was still an associate professor at 49 and that "one could argue that this may be more a reflection of my capabilities than any choices I’ve made about balance in my life." I think we all struggle with those deeper insecurities that, even if I devoted myself 110% to my career (or to my family), I still would be in the same place.

Still, I know I will never win the accolades of my patients or colleagues, because when I was not on call, I rarely made extra trips to the hospital to see that really sick patient or cancelled a family trip to provide management for a difficult case. I will never be the "world expert" on anything because I turn down committees and national meetings and chances to network or contribute to textbooks.

I'll also never be "mother of the year" because I was away at a meeting two years in a row when school was cancelled for snow days. I missed my son's Tae Kwon Do belt test and my daughter's class performance. My husband has moved twice with my career, and he's the one who gets the kids off to school alone most days.

I guess this is a testimonial to mediocrity. Or to averageness. Because what I generally am is content. I will never be doctor of the year or mother of the year, and must acknowledge that I never really had the capability to be either. But with balance and some small success I'm an OK doctor and an OK mom. And most days that is good enough.

Competing interests:   None declared