Notes on a Physician's Life

Reflex resistance to imposed obligations

At a recent business incubator breakfast, I listened to a presentation about goal-setting in the software industry. The speaker described steps he’d instigated as his company COO to keep management and staff focused on their core mission of developing software applications for business. He had created a healthy balance between 90-day targets consistent with the rapid product evolution of the industry and 1-year goals for the overall strategic direction of the company.

The lively debate that followed suggested his approach resonated with his business colleagues and led to my musing on the challenges of having physicians buy into the merits of setting targets for success. We are at best ambivalent about goals and can show a particular resistance when we experience financial or work productivity targets imposed (or feel like they’re being imposed) by management figures, with or without medical degrees to their name.

One part of me understands this and is sympathetic, the other scratches my head and wonders would it be that hard. Don’t our early adult lives not suggest we are masters at goal attainment as we move along over the hurdles of our educational systems collecting the necessary pieces of parchment? Perhaps it’s to do with an ‘imposed achievement-fatigue’ setting in at about age 30?

I’m unconvinced we actually process this at some intellectual level though and see it more as a reflex resistance to imposed and extraneous obligations.Post-hoc rationalizations we may articulate are along these lines:

• Our daily experience of patient care illustrate the gap (or is that a chasm) between ideals and reality - noncompliant patients, variability in natural history of disease or the difficulty of pinning down the multitudinous confounding variables that result in the success or failure of our interventions on behalf of patients leave us skeptical of the merits of targets and the huge gray border zone between correlation and causation.
• We see goals/targets etc. as processes that smack of the corporate and business world. We dislike conceiving of ourselves as working in an industry and have a distaste of working for a corporation, albeit that this may indeed be the case.
• Physicians have an independent streak matched by few other professions. We claim that healthcare is a special case and thus not subject to the usual rules and roles. We can’t really back this up in some particularly factual way so tend to fall back on the sacerdotal nature of our work in caring for mankind insulating us in a way that’s not dissimilar to how many religions, notably the Roman Church of my upbringing, plead their case. A corollary of our independence is hubris. Years ago, a colleague running a large clinical department losing a ton of money told me: “I never pay any attention to young MBA types telling me what to do.” Indeed, all the signs were on it, and, the financial health of his department improved significantly when a more enlightened successor took over.
• Change-fatigue bedevils many members of our profession. Targets and goals mean more paperwork, more monitoring, more time away from patient care and our personal lives. Moreover, once instituted, the goals only seem to multiply.

Yet, having said all that, it’s tough to argue with the merits of goals. We’ve used them to our own advantage as we advanced along the career pipeline. It’s likely we extoll them to our children and out students. So they are good when you’re striving and unimportant when you’ve arrived.

Except.

Except, the real world and real life is all about transition, while stasis is decline or worse yet, death.

And, don’t goals, targets and estimates aid with transition?

My response to the physician anxious to move on but without a clear career alternative.

A physician with whom I’ve been corresponding for some time sent me a two-page email the other day outlining seven different career alternative options he was entertaining ranging from a leadership role at a major medical center (where he recognizes a significant cultural difference from what he is used to and espouses) to life science entrepreneurship (where he knows he’d have to put in 2-3 years to earn credibility) with stops along the way like medico-legal work or joining the federal government.

He ended his email by saying: “I’m really anxious to get out of here…”

Here’s a lightly edited and slimmed-down version of the major themes of my reply:

“Thanks for your update. Well, you are certainly getting a birds eye view of the challenges of setting a new career direction. It’s not an easy process under the best of circumstances and your travails underscore the message I make most frequently to others - if at all possible, make your current situation/circumstances work.

Some specifics:

1. The degree to which your urge to move away from is >>> than the urge to move towards a particular new career option would concern me. Generally speaking the odds of success are low if the primary driver is ‘from’ not ‘toward’. There’s no value judgment on my part about your motives here, just my experience as to what works and what does not.

2. Being a physician leader is enormously challenging, irrespective of the size, prestige or prevailing culture of the organization. If you can size up major hurdles as a job candidate then your instincts to take a pass are likely sound.

3. Your instincts that opportunities with other groups, e.g. in Life Sciences Entrepreneurship, would develop over a few years is correct. Non-physicians are a bit skeptical of the physician wanting to dabble and not being cognizant of the challenges and uncertainties of business. You earn your chops here by putting in your time, consistently networking, sharing your ideas and expertise gratis, and by being affable and amenable.

4. However frustrating it may be to hear it, you have significant domestic constraints with children to feed, clothe and educate for years to come. Thus, you must be prudent in not sacrificing your current position until you’ve a well-defined alternative. In the time we’ve been corresponding, you’ve never really convinced me that there are better options out there, that after an initial period of relief you’d not be back in the soup again.

Best wishes.”

“By creative living I mean not getting killed or annihilated all the time by compliance or by reacting to the world that impinges; I mean seeing everything fresh all the time. I refer to apperception as opposed to perception.”

For several years, I’ve been interested in the degree to which the growing bureaucratization and regulation of medical care is impinging on clinical care. My particular interest is in how these changes are squeezing the intrinsic satisfaction out of medical practice for the physician and damaging the interpersonal dimension for both doctors and patients, and less with clinical outcome metrics or monetary or administrative matters, important as these may be.

One can rail against the daily realities of patient contact hours, wRVUs, complexity of care measurements or other forms of ledgering that irritates your nerve endings, though I’d argue that energy invested there is largely wasted. I’d far rather see physicians concentrate on segmenting off some part of their workday activities where they can be creative in the improvement of their work environment or the direct care of their patients.

Most of us started off life as medical students blessed with flexibility and creativity, but the educational processes of student and resident life, and the drive to be compliant and responsible so we can ascend in the hierarchy often leads to these same qualities ending as prunes, not plums.

The quotation highlighted above comes from an essay ‘Living Creatively’ by the English child psychiatrist and psychoanalyst, DW Winnicott written in 1970 and published in a compilation of his work titled ‘Home is Where We Start From’, published by Norton Press. Note in particular the no-holds-barred language of “killed or annihilated” when it comes to the crushing of creativity by a requirement for compliance or the weight of external forces. Forceful language it may be, and therefore at risk of being dismissed as extreme, but my experience is that it accurately reflects how a number of highly competent and expert physicians feel about their day-to-day work in clinical practice.

What opportunities exist for creativity in our particular workplace is something only we can know. But find them we must if we wish not to feel oppressed and unfulfilled. The well can’t be filled by extracurricular activities alone. The artist may elect mind-numbing tasks that allows them think on the job and pay the bills, freeing them up for their art at home, but clinical practice demands considerable time and mental energy even on a slow day. We physicians must find creative outlets within our work environments. Unlike Winnicott, I’d settle for some of our professional activities being viewable as “fresh”. But those creative elements to our work should reflect back to give greater meaning to who we ourselves are and how we have been shaped by our own life’s experiences, this the ‘apperception” he refers to.

Creativity is for all of us, should be nurtured by teachers, mentors and colleagues, and viewed as a vaccine against being ground down by the mundane elements of our professional lives.

Moving to new endeavors should be done with style.

I’ve had lots of favorite patients over the years. If there’s been a theme to their favored status it’s that they gave more than they got. There was Mabel, who developed epilepsy in her eighties who waltzed on for another decade always giving me a hard time over my ties and how Dilantin made her feel, or the pretty young tennis player at a nearby university with seizures from a massive glioma whose fierce determination to fight an unwinnable fight while never complaining humbled me in realizing how petty I could be with my trivial complaints and concerns. I would I’d have had their lessons stick better, but alas.

For about a decade I took care of a middle-aged professional man with a benign seizure disorder. His twice annual visits were a pleasure. We could dispense with the real business in about 5 minutes and then chat about books, travel, work and life. After knowing him for awhile he told me that he disliked his work despite outward success, and that once his children were out of college, he would retire and move on to other endeavors. The topic would surface every few visits, his story consistent, free of angst or any assigned blame, just a steady determination to change paths.And he did just as he said he would - relocated to a small town in Northern Michigan where his goal was to work in a bookstore. No more high status professional, no more large income. Hello to joy, personal satisfaction, quality time with his wife and quality time for himself alone.

I picture him now, part-owner of a bookstore/coffeeshop in a town half-dead in winter, brimming with visitors in the summer. He’d be in his early 60s, fit and active, even more intellectually curious now that he’s had a decade to read and reflect. I’ll bet he’s a great husband, father and grandfather. I doubt he’s ever spent a minute looking back with regret.He had style. I know that he was excellent at his profession. He walked away with both style and grace, making a new life for himself. He, like my other favorite patients, taught me a lot. I’m grateful.

If a spouse or colleague has been debating career change for 12 months or more with no clear evidence of forward motion, the odds are high that they are really going nowhere.

I took a pass on last night’s Democratic candidate debate. Even political junkies like me have our limit and I’m ready for either Clinton or Obama to move to the sidelines. They can go in the style of Survivor, The Apprentice or American Idol, but it’s time for this oddball triangle to become a twosome. OK, I’ll own up, get off the stage, HC, I feel like I back in Europe again with uber-power in the hands of select families. This is America - we don’t do heredofamilial presidencies here, or at least we shouldn’t - and if we haven’t learned that lesson over the past 7 years 4 months there’s no hope for us at all.

The larger point is you can have too much debate and too much everything else that goes with electioneering. There’s not much more to say except to go round and round like some jaded carousel stuck on the same old tune, numbing your eyes and ears into submission before your brain just shuts off beaten down by the sheer tedium of it all.

I see the same problem with some physicians who are debating career change. Some enjoy the game of dreaming but it’s really a narcissistic exercise where they wear out their welcome in circular discussions with family or friends, or with advisors who are casual enough to permit it. Some want to advance but require a level of reassurance about a leap into the unknown that nobody can in good conscience give them. Some use it as a subtle (or not) threat to family or professional colleagues that they’ll up and quit if they don’t cater to a particular need they have.

Nascent notions of a potential new career direction take a while, sometimes even several years, to bubble to the surface. Once verbalized though it should not take more than 6-9 months for the phase of basic research and discussion to end and a course of action settled on.

If a spouse or colleague has been debating career change for 12 months or more with no clear evidence of forward motion, the odds are high that they are really going nowhere.

If it’s you who have been engaging others in circular discussions about a career transition without progressing into action mode, you need either (1) master the fears that hold you back, (2) acknowledge that you enjoy the ‘game’ of considering change but are never going to do anything significant other than daydream and debate and (3) get serious about revitalizing your enthusiasm for clinical practice.

Peal or plateau, what’s your style?

Peak or Plateau? What’s your style? Life as a series of peaks with the inevitable troughs or the safer steady footing of a plateau? I’d like to break the boundaries of nature and dodge those troughs. To love without falling away from love, to be absorbed without becoming bored or burnt out, to be enthusiastic without becoming blasé. But if I have to take the troughs I will. I certainly don’t want those bland plateaus.
Need it be our lot to fall victim to ennui?
Should we settle for satisfactory?
Does every Likert scale we complete inside our own heads register a 3 out of 5?
Is adulthood about loss of the enthusiasm and excitement and play of childhood?
Why do we calculate risk-benefit ratios before getting off the pot?

Should all adults be required to watch children for an hour a two a month? Sit and in silence observe the play without guile, the absorption and enthusiasm, the concentration, their innate democracy and fairness when in groups, the older looking out for the younger, the peals of excitement. Even the drama of the short-lived crying or tears. The expression of such qualities in an adult is often viewed negatively by other adults. Lack of guile may be treated as naiveté, openness in communication as a lack of political skills, expressions of excitement and enthusiasm or disappointment as immaturity. I’ll warrant they are for some, but for others they are a conscious choice of how to live in the world. They will be seen most in more sensitive human beings, in those who are artistically inclined, and in those whose nature is to resist the grinding down action so well expressed by Dr. Oliver Wendell Holmes: “The longer I live, the more I am satisfied of two things; first, that the truest lives are those that are cut rose-diamond fashion, with many faces answering to the many-planed aspects of the world about them; secondly, that society is always trying in some way or other to grind us down to a single flat surface. It is hard work to resist this grinding down action” (From: The Professor at the Breakfast-Table. 1887).

If we become a plateau, we lose our mountain views. We make little headway in art or in science or technology. If it is true that many of the greatest breakthroughs in a whole range of fields are created by the young, we need to ask why? An open, more plastic brain and mind, or less to lose?

When “the/our/my future” becomes part of the calculus of human decision making, it is almost inevitably a restraining force. One eye on a safe harbor is half the visual power taken off the goal. Does tenure make a professor more or less of a risk taker? Does having an IRA or a pension plan free us up or tie us down?

We were all children once, and played much like every other child free of constraints. Take a look at video clips of children playing in war torn cities, or regions devastated by natural disasters. Examine the works of great photo-journalists like Henri Cartier-Bresson that show the smiles and gaiety of horseplay amid ruins. Thus; the child au naturel. The English novelist, Penelope Fitzgerald won the Booker prize in 1979 for her novel “Offshore”. It’s a short and heart warming book about a small community of misfits living by the Thames river. My favorite character was a small girl called Tilda. Fitzgerald said of her: “Tilda cared nothing for the future, and had, as a result, a great capacity for happiness”.

As we were all children once, for almost all of us our natural rhythms began as those of the peak and trough, not the plateau. But our world grinds away, as if in plateau mode we were better prepared for the grave.

Plateau-mode can be a kind of death. A putting in of time, a diminished sense of self and expectations of what life should offer us. How else to explain the present-but-absent work style of many, including highly educated professionals like physicians, or a present-but-absent home life? The resistance that Holmes speaks of is demanding of us. We can legitimately seek help from colleagues, family, or our superiors. But the primary responsibility to be engaged in our profession, and in our lives in general, and to derive true work satisfaction from them, must remain ours.

You are your own best career advisor. The role of an outsider is chiefly that of fog dispersal, a critical yet preliminary and adjunctive role.

Should you stop me in the hallway today and ask the meaning of desuetude I’d have a puzzled look on my face and answer “I know it but no I just can’t come up with it”, my voice trailing off as I felt I disappointed you. Yet if you’d shown me a sentence in the newspaper like “… after years of desuetude and neglect the old school house was only fit for the wrecker’s ball”, I’d have said “oh, disuse”, though in truth it’s more likely that you’d not have needed to ask me at all.

Such is as it is with words allowing us not walk around with dictionaries in our hands or ones and zeros using up memory in our portable electronic devices. What draws a blank in isolation is easily answered in context. Word definitions are great examples of how much all of us unknowingly know, how context guides us to understanding, and how imperfect knowledge is usually sufficient.

There are similar shades when you turn to me, or another, for career advice. Context is king and you alone know the subtleties and nuances of your life’s circumstances. The job of an advisor is to help disperse the fog that has grown up around your dilemma, the product of your doubts, disappointments, uncertainties and even the desuetude you may have allowed develop over the years about who you really were and what you were really about as you focused on education, meeting the expectations of others, or being swayed by a profession’s culture at odds with your core values.

Clearing that flog allows you see your life in its most valid context. That clarity allows you make the best decisions, drawing on what you instinctively (unknowingly) know about yourself and move ahead accepting the imperfections in your self-knowledge and understanding and that a new direction is right for now but not necessarily for forever.

In short, you are your own best career advisor. The role of an outsider is chiefly that of fog dispersal, a critical yet preliminary and adjunctive role.

Separating flirtation from real intent to change careers.

When you’re on my end of the telephone line or the email inbox it’s relatively easy to distinguish physicians enjoying a brief flirtation with a career change (the many) from those seriously engaged (the few).

Personal dedication to the task is the first determing point, which I reduce to the mnemonic CARE. If you are serious about the process I should be able to detect all 4 of these self-explanatory qualities as you invest your energies in the exploration of career alternatives. Possession may not guarantee success, but their absence signals certain failure.

• Concentration
• Attention
• Reflection
• Emotional engagement

Assuming you have these qualities the next determining point is whether you can endure the inevitable ups and downs in career transition, a process that tends to draw on many of the same characteristics that allows some to enjoy lasting personal relationships while others are stuck in a perpetual dating game.

In the 1970s, while studying business executives, Dr. Suzanne Kobasa developed the concept of “Stress Hardiness”. The more stress hardy executives had three distinguishing characteristics. I’ve adapted the three Cs of Kobasa [and added a fourth] to the issue of career examination as follows:

• Commitment: Physicians with a strong sense of commitment to themselves, their families, their work or a personal cause. They believe in their self-worth. They want either to feel better about their current field of professional engagement or find other outlets that will suit them better.
• Challenge: Physicians who see life as a challenge, welcome considering new career options, and see opportunities not obstacles, and potential not problems.
• Control: Physicians who feel a sense of control over their lives, and pay attention to the power they have, rather than feeling at the mercy of external influences.
• Confidence: Physicians with self-confidence in their ability to solve their career dilemma. This confidence is both a byproduct of their commitment, love of challenge and sense of personal control over the outcome and serves via feedback to engender yet more of those qualities.

Every physician who successfully completed medical school, residency and years in practice has these personal characteristics embodied in the CARE mnemonic and the capacity for stress hardiness in abundance. Marshalling them now in your own self-interest is within your capability, and will keep your career assessment moving forward provided your desire for career change is a deep seated one and not some flirtation borne out of transient dissatisfaction and the desire for an easy out.

How much talent goes to waste as a result of the vagaries and vicissitudes of our existence?

I spent yesterday evening at a solo recital by the 25 year old virtuoso Chinese pianist Lang Lang, the man the New York Times considers “the hottest artist on the classical musical planet.” He almost triggered spontaneous combustion from audience applause after his interpretation of the technically demanding second movement of Schumann’s Fantasy in C Major, stopping progression into the third and final movement until normal operating temperatures were restored. Is this the level of talent we mean when we speak of ‘God-given’ gifts? How else to explain how a child begins piano lessons at 3 years and wins a competition and performs publicly by age 5. Even if his mother did not sing traditional Chinese melodies and his father did not play the erhu, the Chinese two-string fiddle, all facts gleaned from my concert program, would such ability have forced its way to the surface like a bulb at Springtime?

An even more interesting question concerns those who are blessed with great latent talent, perhaps not the one in a billion like Lang Lang, but substantial ability nonetheless. If genius talent, like Lang’s will break through irregardless of obstacles as if a plant growing despite being planted in concrete, do slightly lesser talents need a hefty dose of good fortune of being pointed in the right direction, having a musical instrument or golf club placed in their hand or getting an easel or chess board for their birthday?

How much talent goes to waste as a result of the vagaries and vicissitudes of our existence?
Is there a nascent Tiger Woods or Vera Wang or pick your own favorite in all of us?
Do we just need the good fortune of parent or teacher placing the perfect substrate for our latent talents in our hand or our line of sight?

For at least a proportion of physicians experiencing professional frustration or disillusionment the problem has little to do with the particularities of their workplace, even if they don’t see it that way themselves, rather a sense that some other opportunities are being missed out on. Latent talents may be known and unrequited abandoned long ago to pursue what for some is the siren call of a successful professional life. In the case of others there may be vague senses of other potentialities or in the case of some just a vast sense of the unknown.

Some part of career examination should include inventory taking of roads not taken earlier in our lives. Lang Lang we may never be but you could be a couple of steps below Lang Lang in the Pantheon and still be one fantastically talented pianist.

The fall back position of returning to clinical practice is a poor prognostic sign in physicians exploring non-clinical opportunities.

At a photography exhibit last weekend I saw a technically excellent yet artistically unimaginative image of a series of open doors revealing other interiors as if to reach some infinite and unknowable space - charming but a photographic cliche. I thought how rarely we see images of doors in parallel along some long corridor. There may be technical reasons related to field of view but the real limitation lies with these images being redolent of the banality of daily life which we’re all trying to escape some of the time, while images of doors in series emerges more from the hopes of our dreams both in wakefulness and in sleep.

Real life intrudes, disabusing us of our illusions, forcing us to confront real realities and make our best of them.

Real life is more about journeys down door lined corridors behind which most interior spaces are shallow. The challenge is to find the doors that open into spaciousness, an achievement only possible when we securely close the doors we’ve already opened and not leave them half-open inviting hopeful wistful looks back.

So when physicians considering career changes speak of being able to fall back on clinical practice if some non-clinical initiative fails to develop I know this is a poor prognostic sign for ultimate success. It’s the equivalent of someone marrying yet keeping their list of former girlfriends or boyfriends close by them.

None of us have unlimited potential even while we may have more potential than we give ourselves credit for. Reaching that potential requires firm closing off of those spaces we’ve already looked into and rejected - it’s in walking into a room and closing the door to the corridor behind us that we may see the potential within the space.

Hard to render such nuance in an image of course, just as it’s harder to pull this off in our real lives. I concede the attractiveness of the daydream and the dream like image of the doors opening up towards each other - dreams have their appeal, but they don’t put food on the table or lead to real accomplishment.