Many medical marriages are happy, fulfilling and satisfying. Doctors are bright, well-educated, caring and thoughtful people and so have many of the necessary ingredients to be wonderful partners. Yet, we're not always available to offer these attributes to a significant other. The stress of medical life can put a serious strain on an intimate relationship, whether it's marriage, cohabitation, or a same-sex union.

The closest relationships of physicians are largely unstudied. Much of what we do know comes from older, male physicians in traditional marriages with stay-at-home wives. Our current understanding is that the divorce rate of physicians, both men and women, is similar to that of other professionals.

Drs. Glen Gabbard and Roy Menninger studied physicians' marriages over a 10-year period of workshops for docs and their families. Some of their findings follow.

Doctors are highly conscientious and strive for perfection. We feel very guilty if we don't meet our level of responsibility. There's a need for control, largely to ensure the best possible outcome (for which we feel accountable). We need to please others and gain approval. We're able to delay our gratification -- having done this through long years of med school and residency to get to where we presently are.

Yet, these same qualities can lead to relationship trouble. Patients don't complain about these traits, nor do peers. In fact, we ourselves don't complain either. Spouses, however, do. In the drive to be responsible, perfectionistic, conscientious and approved of, we docs put off meeting our own needs and often the needs of our family. We do that one last round on the wards before we leave, thereby delaying dinner; we dictate proper, detailed, lengthy reports that take time and energy; we sometimes don't book holidays when there's a staff shortage.

A natural evolution
Changes in relationships are normal. When we first meet and fall in love, we come as close as healthy people can come to being psychotic. We lose a sense of connection to time and reality, wanting to be with that other person every minute, thinking of them constantly, pushing ourselves to do things even when we're exhausted. This is not sustainable, though, and things usually settle after a few months. Couples require a sense of secure bonding and emotional attachment. The number one cause of separation is a loss of friendship.

Dr. Michael Myers is a Canadian psychiatrist who's worked with physician couples for years, and has identified some warning signs of trouble:

• tension, irritability, insomnia, anxiety
• physical symptoms
• not feeling loved or appreciated
• not wanting to go home after work, even if tired
• self-medication -- use of alcohol, drugs, medications
• increased awareness of attractive or interesting people in your life
• fantasies of separation
• children acting out and symptomatic of the problem
• arguments, anger, violence
• avoidance, withdrawal, detachment
• lack of sexual intimacy
• fantasies of affairs, acting on these thoughts, affairs.

Often, when we sense any difficulties in our personal life, we exercise the same set of skills we use at work -- we do more, manage more, endure more, achieve more, deny more. We work harder, longer hours, in an unconscious attempt to avoid addressing problems. Unfortunately, this doesn't work well in the long run.

Warning signs
Dr. John Gottman is an American psychologist who's studied couples closely and intensively. His work tells us that the average time that a couple waits between realizing they're in trouble and seeking help is 6 years! He reminds us that it's normal for things to go wrong in a relationship -- what matters most is the ability to repair them when they begin. Seventy percent of marital woes are perpetual, that is they keep coming up and are not going to go away. The goal is to have constructive dialogue, not a fight, about them. Dr. Gottman describes the Four Horsemen of the Apocalypse -- behaviours that are predictive of divorce -- namely:

• attack/accuse
• withdrawal/defend
• contempt
• stonewalling, detachment.

At this point, couples drift apart, lose their sense of closeness, don't feel loved or appreciated, lead separate lives and eventually divorce.

The 5 major sources of conflict are magnified if there are additional family, personal or social stressors. These can include a medical illness in the physician, partner or child, aging and needy parents, academic or behavioural difficulties with children, lawsuits or complaints, issues of interracial or interfaith relationships, or gay and lesbian partnerships.

Dual-doctor couples
Dual-doctor couples have relationships similar to those of other two-professional couples. On the positive end, they are two people who are bright, committed, equal, and offer mutual respect. Tensions and difficulties arise when the male doctor considers his work more important than his wife's, and asks her to change her schedule to accommodate family needs, or refuses to move to allow her a promotion or new job opportunity. Sometimes, there's a lack of empathy for the other's sense of commitment to medicine and long hours. It's tough to come home after both people have had an equally long day and accept an unequal division of home and family duties. It's a fact that even when they work outside the home, women have the greater responsibility for this.

Balancing the demands of medicine with our personal lives isn't easy. It involves accepting this as a responsibility, and making a personal choice to do so. This balance is dynamic and requires constant attention and readjustment. There's professional help available through marital counselling, if needed. While the investment of time and energy in our relationship is great, the payoff is greater!

References:

Gabbard GO, Menninger RW. Medical Marriages. Washington, DC: American Psychiatric Press; 1988.

Goldman LS, Myers M, Dickstein LJ.(ed) The Handbook of Physician Health: The Essential Guide to Understanding the Health Care Needs of Physicians. Washington, DC: American Psychiatric Press; 2000, pp 52-79.

Myers, MF. Doctors' Marriages: A Look at the Problems and Their Solutions. 2nd edition. New York: Plenum; 1994.

Sotile WM, Sotile MO. The Medical Marriage: A Couples Survival Guide. New York: Carol Publishing; 1995.