AMA Journal of Ethics^®

Case

Dr. Leigh wanted to go home. He exited the elevator and walked toward the parking garage. It was 6:00 p.m., and Dr. Leigh, an internist, had just finished making his afternoon rounds at a community teaching hospital. It had taken longer than expected. Two of his patients had had family members in the room when he entered, and had each asked several questions. Dr. Leigh had told his wife that he would be home by 5:30, and he was worried that she would be angry with him because she was frustrated the last time this happened—yesterday. He was fishing for his car keys when his pager went off.

The message said that Mr. Thompson, the husband of a patient Dr. Leigh had seen that afternoon had just arrived at the hospital. Dr. Leigh called the charge nurse, who reported that Mr. Thompson was sorry that he had not been present when Dr. Leigh rounded—he had gone to the cafeteria to pick up dinner. Now he "anxiously" wanted an update on his wife's status and the plan for her care.

Just before he left for the day Dr. Leigh had checked out his patients to the doctor on night float, a second-year resident whom he trusted. He knew that the resident was capable of managing any acute events, but he could not deny that, as the primary physician, he was the person who could best explain Mrs. Thompson's status and treatment plan to her husband. He also knew that, were he in Mr. Thompson's position, he would want to hear about his wife's condition from her doctor.

Nevertheless, Dr. Leigh was frustrated by the request to return to the floor. His contract stated that on non-call weeks, his clinical responsibilities ended when the night float resident arrived at 5:00 p.m. Moreover, these extra calls seemed to be happening more frequently—twice this month he had missed dinner because of them.

As he considered whether or not to return to talk to Mr. Thompson, his cell phone rang. He recognized his home number and was sure that his wife or one of his children wanted to know when he would be home.

Commentary

Dr. Leigh faces a number of interesting choices at multiple levels. Immediately, he faces a choice between his family and his patient. He has told his wife that he will be home by 5:30 p.m. and is already a half hour late. Any additional time at the hospital, for whatever reason, will make him later still and leave even less time with his family. On the other hand, Dr. Leigh knows that, were he in the shoes of Mr. Thompson, he would very much appreciate the opportunity to speak with his wife's physician that evening.

Before examining the larger choices facing Dr. Leigh, it is worth noting that he might resolve the situation as it stands in several ways. First, he might call his wife, explain the situation, and see if she and their children would be willing to wait another hour or so for dinner. If he makes a habit of this, his family's patience will wear thin, but they are likely to understand if he is late for dinner once or twice a month. Alternatively, he could phone Mr. Thompson, explain the situation, answer any pressing questions, and offer to arrange a time to discuss matters further with him the next day. Then Dr. Leigh could offer to have his trusted resident stop by the room that evening to discuss the case. This would not only help Mr. Thompson but would also provide a good learning experience for the resident.

One course of action that Dr. Leigh should avoid is citing his contract as a basis for refusing to speak with Mr. Thompson. No one—not the patient, the patient's family, the physician, the physician's family, or the nurses and other physicians caring for the patient—should find such an argument persuasive. The overarching medical objective is to make sure that the patient is well cared for, not to ensure that contractual obligations are met. A contract represents the lowest common denominator of economic and legal conduct, not a full account of a physician's professional responsibilities. The key question is this: How would I want a colleague to care for my parent, sibling, or child in this situation? Trust and compassion are at stake here, and these fiduciary responsibilities trump any opportunity for a quick exit that the contract might seem to provide.

In a longer-term view and at a deeper level, this situation presents Dr. Leigh with a choice about how to organize his practice. The failure to plan is a major source of avoidable stress and consternation. What steps can he take to reduce the tension between his personal and professional responsibilities? In medicine, no amount of planning can prevent every missed commitment, but the increasing frequency of conflicts like this invites Dr. Leigh to address the issue at a systemic level. Could he, for example, ask nursing staff or an office assistant to schedule meetings each day as appropriate with hospitalized patients and their families? Might Mr. Thompson be asked to remain in his wife's hospital room between the hours of 4:00 p.m. and 6:00 p.m., during which time Dr. Leigh hopes to stop by and discuss his wife's care?

Dr. Leigh, like every member of the medical fraternity, is both a physician and a human being, with personal responsibilities such as parenthood, marriage, and friendship. A well-organized medical life is not one in which the physician races back and forth between two rooms, one professional and one personal, each time slamming shut the door and apologizing profusely. A well-organized medical life is a symphony, in which different sections each play their parts, sometimes separately and sometimes together, but always forming a harmonious whole. The personal and professional parts of life should not be in conflict with one another. Instead they should work together and enrich one another. What could Dr. Leigh's family learn if he shared stories of his workday at the dinner table, and how would Mr. Thompson benefit by realizing that Dr. Leigh, too, goes home to wife and children?

In his Nicomachean Ethics, Aristotle states that human excellence involves balance [1]. Often mistranslated and misunderstood as a mean, as though excellence lay in being average or even mediocre, the Greek term, translated as "balance," testifies to the fact that human beings are composite creatures. Our nature is biological, but it is also moral and intellectual, and we must strike the appropriate balance in each sphere. If we do not eat, we die, yet eating too much can be bad for us. In the moral sphere as in the biological sphere, virtues such as courage and generosity require equilibrium. The courageous person is neither timid nor foolhardy, and the generous person is neither miserly nor prodigal. Each requires its own balance. So too does living excellently, which means balancing well the different parts of our nature and the different responsibilities we assume in life.

The greatest joy comes from leading a life that is firing on all cylinders. Life might be simpler if we bore only professional responsibilities and thus did not need to worry about family commitments. Similarly, it might be simpler if we could forget about professional life and focus all our energy on our families. Yet the simple life is not necessarily the best life, at least not for most of the people who pursue careers in medicine. More than a few people are able to strike the right balance between the personal and the professional, and to do so with genuine grace and aplomb. Such people are role models, and we would do well to learn from them. For them, life without family or profession would be less challenging, less rewarding, and ultimately less meaningful. Having both is not easy, because it requires the regular exercise of additional judgment and discretion, but when balanced appropriately, each enlivens and enriches the other.