Medical marriages.

The Medical Marriage, A Couple's Survival Guide was written in 1995 by Wayne and Mary Sotile, a husband-wife psychologist team. While I was always aware that the book was written by psychologists and I felt uneasy reading some of the case studies, much of what they described rang true for my medical marriage and others I have learned about through career counseling with physician executives.

I have been married to two physicians--the first one for two years, the second for 27 years. In my first marriage, I followed exactly the statistic listed by the Sotiles: "Approximately 50 percent of American medical students marry before graduation, and nearly 60 percent of such marriages end in divorce, compared to divorce rates of 40 to 50 percent for the general American population"

The stress factor

Medical students are under great stress. "As many as 80 percent of medical students reported having been verbally attacked and 24 percent claimed that they suffered physical abuse (being slapped, kicked, hit, or having things thrown at them) during their training." This is bound to have a negative effect on their relationships with spouses, colleagues, and patients. According to the Sotiles, "Sanctions on the extent to which residents can be worked are being implemented worldwide," but I still hear reports of abuse during training.

Medical students learn to delay gratification for years, thinking life will be wonderful when they finish training. Many cannot turn that behavior off as they enter busy medical practices, and some do not want to turn it off as they would rather work at the office than deal with home stresses. "Once in the 'real world,' medical couples encounter various flavors of stress....On average, male physicians work between 68 and 80 hours per week. Married female physicians, in addition to taking full responsibility for home and family, work 90 percent as much as their male colleagues."

Physicians are usually high-powered, fast-moving people who have a hard time slowing down and listening to others--what has been described in many circles as Type A behavior. "A large body of research supports our clinical impressions that healthy Type A's are among the most happy, most contented, dynamic, and successful people," but stressed Type A's tend to accumulate frustrating experiences. People disturb them; they annoy people. "In the words of one of our patients: 'Type A stands for Aggravated. What with? Type B, B, B, B! As in: 'Move your Big slow Behind out of my way so I can get about my Business and lower my Blood pressure!'"

"The most fundamental way of examining the stress in your life is to ask a simple question: When it comes to meeting my needs, is the territory of my life mostly toxic or nurturing? By toxic, we mean anything that makes you feel anxious, frightened, miserable, or generally uncomfortable. By nurturing, we mean anything that makes you feel reasonably secure, appreciated, and acknowledged." We most often look to our marriages to provide that nurturing. "We eventually develop a quiet refrain that organizes much of our psychological and behavioral energy: Will I be loved in a way that satisfies my needs and soothes my fears?'"

Renegotiating the marriage contract

Just like everyone else, medical couples "...find that life ends up being far more stressful and complex than anyone anticipated." In an intimate relationship, "growth...depends on your ability to renegotiate cooperatively, lovingly, and periodically your relationship contract. None of us--no matter how dynamic we are--will be an exception to this rule."

My husband and I seem to have renegotiated our marriage contract about every five years--when our children were three and five, when we moved so he could become a medical director, when I went to work full time, when our children left for college, when my father died, and when I suffered some illnesses. Now that our children have finished college and are on their own, we talk about how to really let them go, which means you stop paying for things. You decide again and again how you will be married.

The Sotiles say particularly stressful times are when a child is born or a parent dies. "The stress and disappointment that...'occurs when children are born'...can end the relationship or cause wounds that last a lifetime. On the other hand, this is the stage of marriage that welds most couples together. They reach higher levels of intimacy and deeper levels of trust as they clear hurdles that are unique to the experiences of co-parenting."

"Few things change the meaning of life more abruptly than the death of a parent. At such times, we are reminded that there is no dress rehearsal; this is the only life we get. We are also faced with the anxiety, awkwardness, and freedom that come from claiming our positions as the front-runners in our families." It's a time when people can do foolish things, such a ditch a spouse and look for a younger one so that the blush of new sexual desire can chase away the awareness and fear of death. It also can be a time when one takes stock and decides to pursue only personally meaningful activities no matter who would object to a change in income. There is an urgent sense that time is running out.

A particularly stressful time in my marriage was when we decided to move from Charlotte, North Carolina to Orlando, Florida in order for my husband to become a medical director. After he had gone on seven job interviews, I finally agreed to move. It turned my world upside down, and I was miserable. The next year we renegotiated the contract so I could leave town for 24 hours every week to work on a PhD. It meant he had to manage grade-school children while I was gone and while I was studying. I had made a sacrifice for him and then he made one for me.

Many a recruiter will tell you the issue of marriage is an important element in a medical management career. They tell stories of physician executives who have gone for two interviews, have been offered the job, and then the recruiter finds out the spouse won't move. Or the spouse is miserable after they move, and they go back to the previous location. Some couples split over this issue, as the physician executive decides he or she is going anyway and not going to turn down the chance to go into management. Sometimes the spouse says this is not what I signed on for--I thought you were going to be a physician and I was going to be the spouse of a physician in this community till one of us died.

What matters most?

"The way you manage yourself during crucial passages determines whether your marriage endures as your most profound source of strength and support or becomes the most annoying source of stress."

Couples have to decide what matters most. I cherish the support I received from my husband through my father's diminishing health and death. It even helps that we love and baby our dog the same way, which enables us not to baby our grown children and let them go. People make jokes about how couples argue over how to squeeze the toothpaste and put the toilet paper on the roll. You can't battle about everything or you will be miserable.

It doesn't matter that I wipe up spills and he walks through them, that my closet is messy and his is neat, that I leave my shoes anywhere and he always puts his away, that we don't agree on the management of the toilet seat. It is important that I am not going to cook supper every night, that he is going to play golf often, that we have separate as well as pooled money, that the separate money is absolutely free of explanation about how it is spent. You must learn to ignore minor irritations if you expect any peace and harmony. The items on the second list can be deal breakers. Pick the things that really matter, talk them out, and renegotiate the unwritten contract from time to time.

Improving medical marriages

The Sotiles' offer some good advice to medical couples to help them improve their marriages:

* Take many minivacations. Set limits on the extent to which you are available to patients and colleagues.

* View setbacks as learning experiences, changes as challenges, stressful times as necessary steps toward desired goals, and vulnerable feelings as powerful resources rather than weaknesses to be overcome.

* Remind yourself that death is not a villain; it is a friend that alleviates suffering.

* When things are not going well, in a spirit of 'I am sorry that I didn't know better or didn't choose differently,' apologize and empathize.

* Cherish each other. Say nice things to each other and about each other when you are alone and in front of other people. When the person who knows you best says, 'I know you, warts and all, and I still admire, love, respect, and want you,' it touches your heart."

* Seek out experiences that help you grow in healthy directions: continuing education, keeping a personal journal, counseling, meditating, practicing yoga, religion, and so on.

* Take care of your body through regular exercise, relaxation, proper nutrition, and limited use of alcohol, caffeine, and other drugs.

* Visit your doctor, dentist, and counselor regularly.

I go to my doctor annually and to my dentist twice a year. I think going to a counselor is a good idea every five years whether you think you need it or not--what my pediatrician husband used to refer to as 'well baby checkups.' There were some times when I really needed it--when my children were three and five. We went as a couple a year after the geographic move. Then when my children were teenagers, I went once a month, just to vent about frustrations and check out how I was doing. The counselor would listen well, empathize. reassure me, and sometimes give advice about a new plan to try.

Conclusion

"Nothing feels worse than not getting along with one's mate, and few things feel as good as marital harmony." Now that the children are grown and our nest is empty, I am glad that when I look across the dinner table, I think--there's my good friend who is flawed, has changed, but is still the one I most want to talk to, who eagerly awaits to hear the stories I've accumulated on a recent road trip. "When the ethic in your marriage is that you are two good and imperfect people who are trying your best to manage your life, your relationship becomes a place to grow and struggle." The Sotile's book can remind you or help you to create that kind of environment.

Reference

(1.) Sotile, Wayne M., PhD and Mary O. Sotile. MA. The Medi cal Marriage. A Couples Survival Guide. New York. Ncw York: A Birch Lane Press Book by Carol Publishing Group, 1996.

Barbara J. Linney, MA, is the Director of Career Development at the American College of Physician Executives in Tampa, Florida and a member of its faculty She can be reached by calling 800/562-8088 or via email at [e-mail].