Acting up or acting out

The famous father of psychoanalysis introduced the term acting out in relation to his patient, "Dora." Dora abruptly stopped treatment after several months, and Freud attributed her termination to feelings she possessed toward an important figure in her past, a man named Mr. K.

Freud commented, "She took her revenge on me as she wanted to take her revenge on him, and deserted me as she believed herself to have been deceived and deserted by him. Thus, she acted out an essential part of her recollections and fantasies instead of producing it in the treatment."

In contrast to acts perpetrated by disruptive and impaired physicians, this article reviews more subtle behavior that may be regarded as examples of acting out closely aligned with Freud's original meaning and observations. You may recognize some of these behaviors in yourself or your colleagues; if they are noticed by other people, they could spell disaster.

1. Lateness. Arriving late to appointments and meetings is perhaps the most common form of acting out in physicians. Anyone can be late once in a while, but serial lateness suggests an unwillingness to be there. Being punctual shows others that you respect others' time and are eager to participate and help them.

When I was a psychiatric resident, I was required to co-lead geriatric group therapy sessions with a clinical psychologist. The psychologist confronted me after I arrived late to therapy several times. I admitted that I disliked group therapy, and I wasn't particularly interested in geriatric psychiatry. After a string of excuses, most tardy physicians will admit the truth as I did.

2. Unavailability. Whereas lateness may signal an unwillingness to participate, being unreachable demonstrates a total disregard for patients and colleagues. Common examples include turning off your cell phone or beeper; failing to respond to phone calls, emails, and meeting requests; and keeping your whereabouts a secret. Such actions represent a severe form of passive-aggressive behavior.

Acting unavailable hurts the bond and foundation of relationships and is considered unprofessional by most standards. Many physicians figure that, if they are unavailable, relationships will fizzle or colleagues or patients will not have any expectations of them. In either case, these physicians (mistakenly) believe they won't have to deal with anything.

3. Omniscience. On the other hand, some physicians work extremely long hours and seem to be everywhere. These doctors, by accepting such regimes without question, may be acting out an unconscious wish to possess abilities and powers that transcend what is ordinarily thought of as human. Long work hours, however, may have a deleterious effect on physicians' ability to deliver high-quality, cost-sensitive care. Residents and surgeons are most susceptible to this form of acting out.

After months of testimony, hearings and public comment, the Accreditation Council for Graduate Medical Education approved new working standards for the nation's 111,000 residents on September 28, 2010. The new regulations go into effect this July 1. Work hours will be maintained at a maximum of 80 per week, averaged over a 4-week period, but there will be significantly more oversight of first postgraduate year (PGY-1) trainees, including limits on their working hours (a maximum of 16 hours per day).