Education and growth are lifelong processes. An understanding of personal growth and a medical practice's professional evolution will afford insight that can be used to better refine curricular programs to meet the needs of primary care physicians throughout their careers.
In the present commentary, I provide an outline of what I believe is a typical life cycle for a family physician on the basis of my 35-year family practice career. Through this commentary, I hope to generate momentum for curricular change using various models of personal growth espoused by Maslow
1 and Erickson
2 along with other accepted family life-cycle concepts.
3-5 I also explore the emotional milestones required for successful growth in a primary care practice.
As a primary care physician's career unfolds, he or she interprets and responds to the world in ways unique to his or her own character. An understanding of evolutionary dynamics provides a road map in determining and guiding educational objectives allowing for successful integration into the practicing environment. Stern and Papadakis
6 wrote:
Without well-defined expectations, students will not have a clear model to strive for. Educators must design clinical experiences that allow students to see how seasoned practitioners negotiate the dilemmas of medical practice.
Constant, uncontrollable outside forces substantially impact the development of a medical practice. Such forces include personal, business, governmental, and legal issues (eg, pressures from rising malpractice risks
7) along with consistent commercial and financial decisions. Internal forces facing the physician center on the successful integration and adaptation into multifaceted environments critical for a successful career. Certain regressive preoccupations may overcome the physician's urge to complete development as he or she struggles between progressive and regressive forces. An example of this struggle is the physician who, after 30 years of practice, tells his cigarette-smoking patients, “either stop smoking or find another physician.”
8,9
Noteworthy transitions from a physician's early professional life to retirement age might be characterized by adjusting preferred modes of dealing with internal and external demands. Although such reorganizations may sometimes be regressive in nature, most result in heightened rather than diminished adaptability.
10-12
Evolutionary changes impacting effective maturation can be mapped through a career life cycle. The physician's practice life cycle will begin between the ages of 25 and 35 years. Tasks include the following:
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Meeting the various demands and expectations of a new job, family and home life, and finances.
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Goal setting; starting or working on growing one's family and career.
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Developing relationships with consultants and establishing professional networks.
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Developing relationships with staff and patients.
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Beginning to develop autonomy and shedding insecurities.
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Balancing strong intellectual drives with practice demands and cost containment.
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Shaping ethical boundaries on discrepancies that are raised in everyday practice. Through the resolution of these issues, physicians are given an opportunity to amplify their ethical philosophies.
The next segment of the physician's cultivation occurs between the ages of 35 and 45 years. Tasks and focus areas during this time include the following:
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Cementing and reinforcing relationships with other health care providers, resolving non-working relationships, and nurturing marital and familial relationships.
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Continued maturation of relationships with staff and patients.
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Learning to overcome and resolve everyday tension when confronted with conflict, others' anxiety, and differing opinions.
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Individualizing practice style and growing to make it consistent with Maslow's Self-Actualization.
1 In other words, once a physician has attained the basic physiologic, safety, love and belonging, and esteem needs, he or she will begin to meet his or her needs for self-actualization—being the per son in which he or she was “born to be.”
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Shedding some classical medical learning in choosing to follow evidence over opinion when appropriate.
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Mastering autonomy, self growth, and consolidation; becoming focused and more clinically discriminatory in using resources effectively.
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Devoting resources to mentoring and teaching, if possible.
The physician's practice blooms into life and work between the ages of 45 and 55 years. This phase includes the following:
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Reevaluating, reflecting on, and reintegrating the biological, psychosocial, and social components established thus far so that a new balance can be established. Changes here might include entering into new agreements (eg, job changes or promotions), creating new expectations for oneself based on new experiences, cultivating hobbies and interests, and modifying goals.
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Taking stock in efforts to reach fruition and beginning self-fulfillment. A self-review of one's moral compass and professional behavior initiates the physician's recognition of his or her chosen direction.
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Transitioning through the end of children's dependency and the dispersal of family members.
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Avoiding desensitization after years of meeting the needs of the practice and patients.
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Codifying self-awareness skills. To develop perceptive abilities with people, a health professional must ripen his or her identity perceptions.
Late adulthood occurs after age 55 years. This period can afford deep satisfaction, but the tasks here may require the use of previously learned coping skills. Such tasks include the following:
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Coming to terms with life and career accomplishments and disappointments.
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Sharpening accumulated crystallized intelligence to solve problems and make decisions.
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Sorting out organic and sensory changes to adapt to the beginning of the late adult years.
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Managing motivational changes and maintaining an acceptable level of skills.
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Planning for the beginning of disengagement.
Further competencies that need to be achieved, as follows, can be addressed at any point in a career cycle:
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Acquiring the ability to interpret the meaning of patients' narratives, such as vague descriptions like, “I feel bubbles all over my body.”
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Working successfully with people who have competing agendas.
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Learning patient-physician negotiations in difficult situations, such as working with parents who refuse all vaccinations.
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Understanding Affinity, Intimacy, Reciprocity and Continuity described by Carmichael and Carmichael,
13 who believed that a family physician should attempt to develop these professional emotions, skills, and competencies at some level with patients. In other words, instead of having a cold, distant relationship, the patient-physical relationship would be more intimate.
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Achieving anger control and maintaining plasticity of self-development; remaining teachable and resisting the urge to get stuck at certain levels of development.
The transition from 1 cycle to another is gradual, and the tempo may be distinct to an individual's character. The emotional and social development of receptive communication, self-understanding, intimacy, knowledge about other people, relational skills, friendships, and moral reasoning and behavior exist in the realm of evolution. Many professional and personal challenges must be overcome to conclude a successful career. Establishing a balance between helping people and making a living gives rise to tensions that must be mitigated. Learning to balance one's personal life and its influence on a professional career requires constant self-analysis and insight development. The ability to self-reflect and remain comfortable with seeking help in difficult professional life situations is essential. In primary care, learning how not to give up on resistant patients will be profoundly important, especially in the medical home paradigm. With the ability to reflect, question, and self-explore, primary health care professionals can develop the competency to structure and justify their own concepts (eg, whether to follow the US Public Health Service recommendations for mammography
14 or those of the American College of Radiology
15).
The present commentary attempts to document developmental issues during one's career. To address these issues in the current medical training structure, educators have to look to the future. However, several limitations must first be acknowledged. The stages presented in this commentary are intended to represent an ideal physician's career and may not be reflective of all physicians' métier. Suppose 75% of physicians have career life cycles as described above and 25% do not—would this variation affect the design of educational interventions? Furthermore, with the Patient Protection and Affordable Care Act, the projected shortage of physicians,
16 and the aging baby boom population,
16 changes in US medicine are likely in the coming decades. These changes beg the question: Is knowledge of the physician life cycle still a determinant of professional behavior and attitudes?
Unfortunately, research in this area is lacking. McSherry
17 conducted an extensive literature search of the physician life cycle but produced no other investigations of this type of model. Future work in this area should include longitudinal in-depth interviews with physician cohorts. Other investigations must consider whether continuing medical education programs offered to physicians in different decades of their careers are beneficial. How these stages, if verified, might alter educational approaches for osteopathic medical students and residents and is another area for productive investigation.
I call on others in the osteopathic medical profession with the knowledge, experience, and interest in this area to explore it further. Although the content presented here may change and can be expanded, it is the concept that is important. There is a relationship between the curriculum and the professional success of primary care physicians, and a curriculum that accounts for the personal growth, development, and maturation is essential for success.