Wellness 911

FigureFigureFigureFigureShel Silverstein's book models unhealthy behavior that EPs shouldn't emulate Those of us in health care frequently find examples of martyrs for medicine. We love them. They always put others first, never miss work, fill more than their fair share of unfilled shifts. Even when sick, they'll keep seeing patients with an IV attached. They're legends. That's certainly what gets reinforced in our training. But having no boundaries for ourselves and denying our humanity comes at a cost. Some say maybe duty is enough. Surely service is more important than our own preservation and happiness. This reinforced behavior serves someone or something, but it's not us. Our selfless service is reminiscent of The Giving Tree, the beloved children's book by Shel Silverstein. The story about a tree and a boy focuses on the tree's sacrifice. The tree loves the boy so much that she gives him all her apples, limbs, and eventually trunk until only a stump is left. The boy becomes an old man, and when he returns, the tree is sad she doesn't have more to give. He only needs a place to sit, so she happily straightens so he can sit on her stump. The story says she is happy. This level of self-sacrifice is problematic. A New York Times article mused, “To some readers, the tree's act of sacrifice seems noble, like the unconditional love a parent gives to a child. But if you assume the story is about generosity, it's easy to learn the wrong lessons: “that it's O.K. for a child to take selfishly, and that adults should give until it hurts—and keep giving until they literally have nothing left to offer. That's a recipe for trouble.” (New York Times. April 15, 2020; https://bit.ly/3oRQ5SL.) Self-sacrifice is not sustainable or healthy. Sacrificing our own well-being for others leads to burnout, declining productivity, and less effectiveness. Those who care about others and neglect themselves are more likely to become anxious, depressed, even less effective. The article cited research that showed teachers who gave inordinately of themselves were less effective and their students did worse in school. (Harvard Business Review. Jan. 23, 2017; https://bit.ly/43SyqJA.) “Generosity is not about sacrificing yourself for others—it's helping others without harming yourself,” the New York Times article stated. “It's not giving to takers—it's giving in ways that nurture more givers. It's not about dropping everything any time someone needs you—it's prioritizing your needs along with theirs.” We need more examples of healthy altruism. A study of the recipients of a high Canadian honor for giving revealed they scored higher than average on their concern for others but also for themselves. (J Pers Soc Psychol. 2011;101[1]:149; https://bit.ly/3CjCAhB.) This helps them maintain their motivation instead of draining their energy. We'll make a bigger difference in the world if we stop allowing ourselves to get chopped down. We have to be a tree that produces fruit and produces new trees. Some say The Giving Tree encourages selfishness, narcissism, and codependency. (Curiata. July 2, 2014; https://bit.ly/3P56myq.) The boy rarely says “hello,” never asks how the tree is doing, and never says thank you, despite the tree ultimately giving everything. The narcissistic systems of abuse in which many of us work comes to mind. The boy never learns empathy because the tree gives without teaching any appropriate boundaries. Our systems similarly won't do anything differently until we stop putting up with abuses. The tree has some codependency traits—low self-esteem and a strong desire for approval that creates an unhealthy attachment to another often controlling or manipulative person. We'd take it further and say a controlling or manipulative medical system. The tree in the story is sorry she doesn't have more to give than her stump. How many of our colleagues try to be more resilient, stronger, and give more before completely burning out? It's ironic; they're already the strongest, most resilient, most giving people we know. Blogger Christopher Roosen noted that neither of the characters in The Giving Tree really benefited from the relationship. “The tree is effectively dead, with nothing left to give. The boy has taken everything and seemingly learned nothing from the tree's sacrifice.” (Adventures in a Designed World. May 29, 2021; https://bit.ly/45SVGsB.) It is easy to see the similarities in our careers. We end up giving it all, and the system learns nothing. Strong relationships are built on mutual respect, something seemingly missing in medicine. Further, generosity and self-sacrifice are not the same thing. Too much self-sacrifice creates a parasitic relationship that is detrimental to both. The boy might have learned some self-restraint and true partnership if the tree had set limits. Playwright Topher Payne wrote an alternate ending for the book that created healthy boundaries for the boy, allowing the tree to provide fruit for him, his children, and generations to come. (https://bit.ly/45VGWJh.) Those of us in medicine have a duty to serve. That is our job, but it doesn't need to come at the cost of our soul. Doctors in general are incredibly altruistic people prone to giving more than they should. Many of us are giving trees. We have to create healthy boundaries for ourselves. Future generations of doctors need to see what it looks like to treat ourselves as well as we treat our patients (and medical systems). If you need to get home, go home. If you need a day off, don't pick up that extra shift, even if it goes unfilled. Continuing to sacrifice ourselves for a system that doesn't care for us back isn't working. Let's rewrite the ending to our story. 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