COMMENT

http://dx.doi.org/10.5546/aap.2018.eng.308

A vital balance

The article commented here, authored by Schwingshackl and Anand,¹ is a balance -if you will forgive the pun- regarding the impact of a previous article by the first of the authors.² The topic is in line with the growing bibliography about burnout in medicine and about other studies on physicians' self-perceived conditions of medical practice. Since Christina Maslach's pioneer article on the measurement of burnout in the early 1980s, the topic grew exponentially, perhaps as a result of an increasingly stressful daily routine for health care providers.³ It is not difficult to have reliable and updated access to the growing bibliography on this range of issues.^4-6

The editorial commented here, together with the original article by Schwingshackl and those published in response to it, have a typical, selfreferential style, as required by the nature of this subject matter. Basically, Schwingshackl and Anand state that the notion of "work-life balance" is not particularly useful because it raises a false dilemma. However, they admit that the concept itself is pretty much a growing concern among colleagues. Like the authors, I consider this matter to be of enormous importance. But the kind of issue being put forward by them seems to call for some discussion.

The first thing to be said it is that these matters are highly dependent on particular social and cultural values. Certainly, the working and living conditions of doctors living in the West Coast of the United States are hardly comparable to those that may be observed in the major urban centers of Argentina. A global, highly-interconnected world may lead to an "illusion of homogeneity", a mirage that tends to hide the radical differences between daily working and living realities. This does not mean that there is nothing in common between these worlds: one example is the growing awareness of life crises and the worsening of the increasingly complex (or "inhuman", as some might say) conditions of medical practice. The difference seems to lie in the components of such crises, their meanings, and how people may react to them. The burnout phenomenon may be common both to American and Argentinian pediatricians, but it is not the same to be "burned out" by the characteristic institutional pressure and high competitiveness demands involved by a medical career based in Los Angeles than having to be on duty three times per week risking physical attacks from patients and living in a chronically unstable social context, such as is not unfrequently the case in Buenos Aires. Needless to say that the way to conceive life projects, which at times involves starting a family, is also very different from one hemisphere to the other; at the same time, it is evident that images of career development and personal achievement are value-laden cultural products.

Two broad and thereby intimidating topics are taking shape on the horizon-I dare to tackle them sheltered by that kind of impunity conferred by older age. Firstly, for us Latin Americans (and this applies specifically to Argentina), the kind of medicine developed in the United States after World War II became an hegemonic model; local medical traditions attempted with more or less success to become organized upon this model. This is particularly relevant when we touch upon those aspects that make up the social essence of medicine: it is here where dissonances begin to be heard. In the second place, in the 1970s, "social medicine" was just one more approach among others in the vast field of medical practice; now, in the 21^st century, there are few colleagues who would deny that medicine is, above all, a social occurrence (although not just that, of course). The life of a pediatrician in Buenos Aires is very different from that of a physician in Stanford. Can conclusions be extrapolated? I tend to be rather skeptical. Because we would be overlooking the extent to which medical practice depends on the economic, social, and -of course- specific professional structures of each community.

May the concepts of "work" and "life" used by the American authors be considered equivalent to their local counterparts in Argentina? After all, are we not talking about the same "life" and "work"? Schwingshackl and Anand have aptly pointed out that these concepts should actually be considered "constructs" which we use to come to terms with our profession. If such is the case, it is evident that they are built out of the conceptual and emotional materials of the world which immediately surrounds us-the society and the culture in which we live and work. And if we delve into a more refined conceptual analysis, we might ask ourselves: Is not our "work" also a part of our "life"? What are exactly the grounds of the "work-life" duality? Is it possible to trace a neat divide between these notions? One thing are the late night melancholy chats over burnt coffee, in which we can indulge in loose talk about "life", "work", and the like and a different thing are the analyses that result in articles published in journals. Can we freely move from one dimension to another? With the use of such kind of notions, are we not entering the world of self-perception, the realm of highly-subjective values and situations? It is at least a matter of discussion up to what extent these topics should be subjected to statistical analysis; one of the advantages of the editorial commented here is that, in this respect, it stays on this side of the fence.

In short, as pointed out by the authors, the most interesting part of this issue may be the discussion itself. Because the matter is real: What is the life of a pediatrician like, his/her life as a doctor and his/her personal life, in this or that particular setting? What opportunities for personal planning or development are implicated in the different ways of being a pediatrician or practicing pediatrics in Argentina? Moreover, based on a language that, as such, is fraught with preconceptions: Is it the same to say "being a pediatrician" as it is to say "practicing pediatrics"? All this deserves to be discussed, and perhaps, formally. Of course, the experience described in the international bibliography is extremely valuable. But we should not overlook the fact that these matters, which are increasingly more and more complex, are as old as the medical profession -and, indeed, as humanity.

Miguel de Asua, M.D., Ph.D

CONICET-UNSAM

REFERENCES

1. Schwingshackl A, Anand KJS. Editorial: Work-Life Balance: Essential or Ephemeral? Front Pediatr 2017; 5:108.         [ Links ]

2. Schwingshackl A. The Fallacy of Chasing after Work-Life Balance. Front Pediatr 2014; 2:26.         [ Links ]

3. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav 1981; 2(2):99-113.         [ Links ]

4. Mahan JD. Burnout in Pediatric Residents and Physicians: A Call to Action. Pediatrics 2017; 139(3):e20164233.         [ Links ]

5. Baer TE, Feraco AM, Tuysuzoglu Sagalowsky S, et al. Pediatric Resident Burnout and Attitudes Toward Patients. Pediatrics 2017; 139(3):e20162163.         [ Links ]

6. West CP, Dyrbye LN, Erwin PJ, et al. Interventions to prevent and reduce physician burnout: a systematic review and metaanalysis. Lancet 2016; 388(10057):2272-81.         [ Links ]