Notes on a Physician's Life

“Perfectionism undermines and destroys its own basic purpose.”

A sturdy, resilient streak of perfectionism runs through my nature. I’ve turned it too good effect in many arenas of my life but it’s undermined me to equal degree. It works well for some patients and colleagues but an equal number find it excessive if not oppressive. My wife, blessed with abundant serenity and a sure sense of self, screens it out, placidly staying on her path, while reminding me to “slow down and take it easy”. I try. I fail. I try again. I fail again.

I’m thinking of having the quote above, from George Kennan, the historian and political scientist, emblazoned above my office desk, a reminder of the opportunity costs of perfectionism in an imperfect world.

I’ve lots of company among members of the medical profession.

Sam, an accomplished internist, would seem to have it all. Trained in medicine and his subspecialty at a prestigious medical center, talented at procedures that net him and his practice partners a steady stream of patients and revenue, blessed with a delightful wife and three healthy children, yet….
Sam, beneath the surface calm and success, is not at ease. Ten percent of his mind is always off in another world where words like meaningless, futility and restless abound. Ten percent of the time he’s absorbed totally with such glass half empty emotions.

He can’t seem to make up his mind whether to enjoy or endure.
What has he achieved or is yet to accomplish?
Which matters more - that which is easy or that which is difficult?

He sees the absurdity but can’t stop himself. A young adult life of constant striving has corrupted his neural networks to strive to improve while procrastinating on enjoyment. He finds himself hard to live with. his wife and children feel this too. Most of his colleagues and support staff sense this tension, admire him for his abilities but also find him tough to tolerate.

Sam could be a poster child for the perpetually perfectionist physician. An attribute whose kinetics are non-linear, where toxicity is all too common, where a variation on the adage that saints are hell to live with all too accurate. Saul Bellow put it eloquently: ” Some people embrace their gifts with gratitude. Others have no use for them and can only think about overcoming their weaknesses. Only their defects interest and challenge them.”

A not insignificant amount of the career dissatisfaction expressed by many physicians has a Sam-like quality to it. Most importantly, no career changes, no amount of career advising can accomplish much without an awareness of this quality in those affected coupled with an unbounding determination to change it.

One must, pun intended, be a perfectionist in decoupling our need to be a perfectionist. Thereafter, all things are possible.

The costs of overly dutiful doctoring

Duty was a great word in my family. There was doing your Easter duties, cleansing your soul for Christ’s resurrection. There was the more generic ‘being dutiful’ - to parents, grandparents or teachers but they were all poor human surrogates for God. The word triggered a near reflex in me of dropping my head and shoulders and closing my eyelids as I’d murmur “yes Mummy” or yes to some dog-collared reverend - all good training for doctoring I suppose.

A surgeon at a local medical center emailed me a while back to express frustration with his professional success. He said: “I have a bunch of hobbies .. and no time to do them, but I’m hopelessly addicted to the satisfaction of helping people..”

“Hopelessly addicted” is quite a confession. Life as an ace clinician is an intoxicating reward that carries a substantial opportunity cost. And, if unlike my colleague you don’t recognize this, your family knows better.
You are not home enough.
When at home, you’re not really there.
In the shower or the car, you think about your family and other interests and remind yourself that now is the time to give them attention. The next morning, back in the hospital, absorbing the ambrosia of success, you slide back to square one.

The demands of contemporary medical practice on the successful physician’s physical, emotional and temporal resources outstrip supply. As a rule, family and outside interests are likely to be subordinated to professional endeavors.

Many physicians feel caught in the cross hairs of this dilemma:
If I am available to my patients, students and residents, colleagues and support staff, the way I should be, where is the time for my family and friends?
If I neglect my family and friends, will my sensibilities change my patients and those whom I mentor be disadvantaged?
If I dedicate myself to remaining current in my field, do I by default neglect the humanities or other non professional enthusiasms that keep me interesting and feeling well-rounded?
If I neglect the humanities or other avocations, will my sensibilities change and my patients and those whom I mentor be disadvantaged?

And so on.

Feeling over-extended is close to endemic in the medical profession today. Our high threshold for tolerating personal distress and delayed gratification that got us into and through medical school and residency training comes to our rescue. An overly developed sense of duty and responsibility - what I’m terming deontological doctoring is a trap for at least some of us. But at what cost?

Why do so many initiatives within a family or a work family falter?

Whether carefully considered or impulsive, beginnings are relatively easy. Words like engagement, excitement, enthusiasm and energy abound, until, almost inevitably, an end arrives. Pain, sadness, grief, frustration, or at the very least disappointment then emerge and often linger sometimes lengthily. Business or pleasure, professional or personal, it’s as if an inviolate rule book was being followed.

Why do so many marriages and personal relationships fail? Why is the failure rate of business at the 80% mark? Why do so many initiatives within a family or a work family falter?

Choose well, build a business plan, lay the groundwork, do the background research, we’re told.
Many do, and still fail. They fail, we fail, I fail, because neither they, nor we, nor I manage the middle adequately.

Who is more likely to have a lasting relationship? A couple perfectly suited to each other who assume that’s sufficient and meander along through life doing their own thing, or a couple sharing less in common who regularly reshape their relationship. A medical practice that sees an opportunity, develops a business model and ploughs straight ahead, or one that is constantly refining their mission and practice model.

While the questions can seem as pedantic as the answers are obvious, there is a disconnect between what we know and how we act. When these same truths are pointed out to an individual or group, their disappointment is often palpable. We sought the wisdom of Solomon, and this is your answer?
Yet, if such truth was incorporated into our work and life, there would be no need to solicit advice or seek consolation in the first place.

In a nation renowned for offering second, third or more chances, the opportunity to end and move on amounts to a right. But when are we going to face up to the costs of an unending cycle of peaks and troughs? Has the financial meltdown of the last year finally hammered home the destructiveness of such cultural forces?

I’ve heard wonderful visions expressed, I’ve espoused grand missions myself. But more business plans, mission and vision statements, and marketing plans end up gathering dust on bookshelves, rendered obsolete in a week or a month by factors unanticipated at the time of their production. I’ve witnessed and participated in personal relationships, chock full of optimism and excitement at onset, yet all too quickly slipping like quicksilver through my fingers.

A modern-day philosopher, Woody Allen, pointed out that 80% of success in life was showing up. This writer, says that 80% of any relationship is spent in the middle. The critical middle. It’s the middle that determines the nature and quality of the end.

Not everything can last. But should we not be talking about 20% rather than 80% failure rates? We can only get to that lower failure rate by concentrating our efforts at home and at work on the critical middle stage. That is achieved by methodical management, consistency, attention to detail, and frequent minor adjustments. It is not high drama, of appeal to the media, or even ego-boosting. It requires us to shelve our almost reflex dismissal of “middle-management”. It is middle-management that makes our personal relationships and work enterprises thrive. It is what turns the world.

Robert Frost may have taken the “road less traveled”, but I’m guessing he stood at the diverging point in the woods for a while and pondered.

Early in life we all became expert in carefully orchestrating our last few puffs on a dandelion so the final seed floats away on an up note. She loves me; that microcosm of life imbued firstly with hope, but secondly with our need for clarity. Maybes, doubts or ambiguities lead us to fret. We’d sooner a poor outcome to a period of uncertainty.

Our language is replete with phrases like:
“I want to know where I stand.”
“I can deal with anything, just so long as I know.”
“Don’t leave him/her/it hanging”.

Pejoratives abound when certainty is in short supply, especially in our dealings with others:
“He’s full of self-doubt.”
“She lacks self-confidence.”
“He’s so indecisive.”
“She can’t make up her mind.”

In the medical profession we may disparage colleagues who fail to show what we view as the right stuff.
The colleague who orders more tests and consultations than we would - “clinically indecisive”.
The colleague who admits more from the ER than we say we would - “a sieve”.
The pathologist or radiologist who wants more studies - “that chap can never make up his mind about anything”.

However much we try to iron out the creases that are the uncertainties, doubts, what ifs and maybes, they are integral to the fabric of our lives and our relationships. Robert Frost may have taken the “road less traveled”, but I’m guessing he stood at the diverging point in the woods for a while and pondered.

And, so must you, to pass through to a different phase of your career. Instantaneous epiphanies are as rare as the dodo. Doubts are the stuff of an enquiring mind. Tolerance of ambiguity is a measure of personal maturity. An understanding that the answer emerges from an at times difficult journey and search is the mark of personal responsibility. Unspoken by Robert Frost, perhaps, but just the same, implied.

If an icon like GM can be brought to its knees, could a similar fate await the medical profession?

Below is a lightly edited version of a post I made to this weblog on June 16th 2005. I thought it worth revisiting given the calamitous fall in GM’s fortunes since I wrote this originally and in light of the major changes that will be needed by members of the medical profession, among other constituencies, if healthcare reform is ever to happen in the United States. GM just would not budge. Will we physicians be more pliant?

December 28th 1979. My second day in the US. I purchased a new dark claret-colored Chevrolet Monza for the princely sum of $5,000 at Clements Chevrolet beside Apache Mall in Rochester, Minnesota. My first new car, ever. I was excited.

December 29th 1979. Day 2 with my new car. It wouldn’t start. As I recall, the crankshaft had split. It was as if God had spoken: “GM cars are trouble”.

In about a generation, GM has been brought to its knees. Its market share of near one car in two in the 1950s is now one in four and falling. Its bond rating was recently downgraded to junk status. The GM star has gone south, even as company efficiency and product quality improved. Nobody can say how reduced the corporation will ultimately be, or if it will survive at all.

No matter how big or powerful an organization, perpetuity is not a guarantee. Examples surround us, like Sears, AT&T, or the three major TV networks, all pale shadows of who they were a decade or two ago. Could a similar fate occur to a great profession like ours?

A house guest told me recently that he might need surgery for a bunion and if so he’d see a podiatrist who does just this operation and gets excellent results. People flock to complementary and alternative medicine centers for multiple different ailments, and are more likely to see psychologists or social workers to discuss their personal struggles than to see a psychiatrist. Within clinics or hospitals, much care can and is provided by nurses, physician assistants and nurse practitioners. In these contexts, many patients find the non-physician more approachable, more patient and more empathetic.

When really ill, or with their back to the wall, members of the public head straight for good doctors. But most illnesses or distresses are minor and transient and commonly patients seek alternatives to physicians. We’re seen by many as expensive, arrogant, impatient, unempathetic, even when, just like GM, we’ve improved our attention to patient satisfaction.

I’m a physician, and the son, nephew, brother, and cousin of physicians. I dislike seeing my profession viewed this way, but I also accept that some criticism is warranted. Drawing an analogy between the state of affairs in how the public views doctors and their search for alterantives and the fall of GM may be too much of a stretch. But can we be sure of that? How many cognoscenti 20 years ago would have predicted the staggering decline of GM?

In our world of fast-paced change, both presumptions and predictions are fraught with hazard. But the best solution to the potential problem is to address it now, rather than waiting to see how events transpire. Overall we are not a user-friendly profession. Too many of our systems are established to facilitate the physician rather than the patient. We’d to well to change this.

Instinct in decision making - fact or fiction.

Weeding is hazardous in one part of our garden at present. I’ve been dive-bombed multiple times the past two evenings by a high-achiever robin mom who views me as some nuclear equivalent threat to her nestlings. I admire her pluck while publicly scolding her for rousting the neighborhood - perhaps she’s a first-timer, I tell myself.

‘Bird-brain’ we may say in dismissing the non-sapient members of our own species but we may be unfair to avians here. Watching robins perpetuate their species each spring is cause to marvel at the might of instinct. I wonder whether human equivalences haven’t been subjugated or altered by education, socialization and experience to the degree that what we may term ‘instinct’ is more a surrogate antonym for these three attributes than any worthy phenomenon in its own right.

“My instincts tell me I erred in coming to work at this institution”, says a colleague. Most times when we ascribe a decision to instinct we’re drawing, knowingly or not, on what we do indeed know. It may suit us to chalk-up our decision to instinct and thus forgo the need to justify or rationalize it to our own selves or others or to obfuscate. Our unknowing knowing (a product of denial or other psychic defenses) should not be construed as an equivalent to the robin’s instincts - she genuinely hasn’t a clue - we don’t realize that we do.

This still begs the question whether we have instinct. In other words, are we able to act in our own best interests independent of education, socialization, experience, denial or any of its allotropes, and primitive energies chiefly weighted towards sex or survival?

Robins mate, nest and mother guided by the North Star of instinct alone. I suspect there’s an equivalent in humans, emerging for example at those coup-de-foudre moments where we just know something about someone or some situation without prior knowledge. I know no way to prove this however and can conceive of no thought experiment to isolate it.

I’ll leave the last word to Dante who, to my interpretation was a skeptic about human instinct:
“Man does not know whence comes his understanding
Of the existence of first principles,
Or of the trend of primal appetites
Innate in you, like instinct in the bee
For making honey; and this primal will
Can never in itself be praised or censured.
But so that all may harmonize with it,
The faculty of reason is inborn,
And should defend the threshold of assent.”
[Virgil to Dante. The Divine Comedy. Purgatorio. Canto 18.
Trans. Lawrence Grant White 1948]

Realities for the tyro physician consultant.

A novice at consulting was despondent at the lack of followup beyond the agreed temporal parameters of his project. He saw himself more ‘in’ than his client institution, he sought appreciation beyond the check, progress reports, some sense of espirit de corps; he sought in vain.

I have a scribbled note that says “Balzac citing Aristotle - ‘ of all human qualities, gratitude stales the soonest’, next to which I wrote ‘consultants know this’”. I can’t track the source at present. It doesn’t come up on google or in my quotation books and I’m too busy with consulting projects to devote more time to source the citation and insufficiently successful to employ research help. In any case it’s close enough and sufficiently apropos that all tyro consultants should have it (in needlepoint) over their desks.

There’s a slightly meretricious quality to the whole world of consulting.
You promote yourself.
They select you.
Your proffer your skills but you’ll be used to suit their needs and wants.
They pay.
You go.

Maybe there’ll be more visits. Maybe not.
The quality of your work may have little to do with this. Institutions, organizations and individuals too are remarkably fickle when dealing with outsiders.

Intrinsic rewards from consulting work must come from what it offers you, matters like autonomy, enhanced family time, opportunities to scale back or pursue alternative interests. You will of course get feedback and positive strokes and followup work from some clients but it’s unpredictable and better off not being relied on. Take it as a bonus when proffered, shrug the disappointment off if it’s in short supply.

“They are passing, posthaste, posthaste, the gliding years..”.

“After this nothing happened” was the lapidary statement of Plenty Coup, last great chief of the Crow Nation, in describing the impact of his tribe giving up their traditional way of life and living on a reservation late in the nineteenth century. Life went on, except it didn’t. Their activities, customs, habits and interests were all foreshortened, fundamentally altered, corrupted by a forced fit into an imposed way of life.

Fear of a parallel experience confronts many successful professionals who consider retirement or a major career realignment. Nothing happening is a reality for others who retire irrespective of age. It can’t be dismissed as depression. It’s more complex than some existential struggle, because it’s root is the tangled twine woven between our own private personal world and our profession.

Important as financial health and independence are, way too much retirement planning focuses on the size of our investment portfolio, way too little on our portfolio of extra-professional interests and activities, or, as importantly, on profession-related adjunct interests and activities. Golf and grandchildren have their place but will prove insufficient for most physicians. What Nabokov called our “gliding years” can pass pleasantly, yet many seek more than gentle movement through life at the discretion of thermals we can do little but react to.

Elements for optimum late-career or retirement (I’m skeptical there’s a real difference) planning includes:

• Financial planning.
  While not the sole focus of our plans, it should begin as early in our income earning years as possible. Financial security may not guarantee happiness, but it can grease the wheels to getting there. The current chaos in the financial markets underscore the merits of a significant financial cushion.
• Mental and physical wellbeing.
  Nurture your personal relationships, start yoga and a daily baby aspirin in your forties, read for several hours a week, or find your own means to the end goal of being a vibrant man or woman in the later stages of professional life.
• Develop some interests at a complete remove from your professional life.
  It might be golf or tennis, woodwork or photography. Find a range of activities, some that you share, some that you have independent from your spouse. If some offer the opportunity for helping sustain healthy relationships with adult children, so much the better.
• Develop adjunct professional activities.
  See Illustrative Non-Clinical Careers for some examples in essay III.5. You can counsel young athletes or young entrepreneurs, you can teach nursing or med tech students at your local community college; the possibilities are limited only by your imagination, your interest in seeking primarily intrinsic i.e. non-monetary rewards from these efforts, and your determination to find areas of continued professional engagement.
• Reshaping formal professional activities.
  Age is no barrier to performing excellent work in many clinical fields. If minded to continue to contribute we would do well to reshape our clinical effort to facilitate this as well as making room for those coming behind us. Physicians in non-procedural fields usually have an easier time but even surgeons can pick less intense work. I know orthopedic surgeons who limit their work to pre and postoperative assessments, neurosurgeons who work in clinics supervising residents and vascular surgeons who do vein work only.

It’s about time to retire the word retire from our lexicon. It’s one more innocent word that has got stuck with a pejorative aura. Why retire? Why not just continue along, but operating in a different professional orbit, one developed over 10-20 years ago, slowly compounding just like your investments are supposed to?

Find people, practices and organizations that share your values.

Jean de La Fontaine was born in a small town about 50 miles outside of Paris in 1621, and published his three famous sets of fables between 1668 and 1693. His fable, “la grenouille qui se veut faire aussi grosse que le boeuf” or “the frog who wanted to become as large as the ox” is short, sweet and simple. Ok, not for the frog, who basically was an idiot. The frog spying an ox admires its size, and tried to strain and swell to match the ox. Outcome; one burst frog!

Moral: Size isn’t everything; (how’s that for being original). Nor is your job title, salary, what your colleague in the next office or examining room thinks, how many papers you wrote, and a lot of other stuff in life.

Figure out who you are, what matters to you and your spouse/partner and family. Ignore the prevailing orthodoxy which is all too often the dreary self-serving value systems of others, either individuals or institutions. If they are incongruent with your values, find people or practices or organizations that share yours.

There is nothing more impressive than a human being who seems to be truly comfortable with themselves, a frog if you will who enjoys being in the frog zone. Woman or man, young or old, tall or small, beautiful or ordinary looking, rich or poor, they are powerful and wonderful to be around.

Career advancement happens via personal connections – networks rule is the rule.

Each evening, prior to dinner, I stroll to the mailbox, a walk of some 100 yards. Returning, I sift the mail into outright junk, likely junk and the real deal. Entering the house via the garage door I toss the outright junk into the recycle container, pausing momentarily (code for a few nanoseconds) to open and check the likely junk before consigning it to the same end, then enter the house. If you asked me 60 seconds later what constituted the junk mail I’d be unable to tell you. I’ve probably moved on by then to answer the phone to some telemarketer or quickly culled some more spam for viagra, cialis, or fake Rolex or Bulgari from my inbox.

You’re doing much the same, I expect.

You can anticipate about the same level of responsiveness to your initiatives to find a new professional opportunity when you call or mail blindly or send off your resume via an organization like monster.com - sure, they’ll tell you “connect with top talent like never before”, or “post your resume and let top employers find you.” But as every physician who’s gone this route has told me - it’s a colossal black hole, and those who broadcast their CV broadly and sit back waiting for the phone to ring are spreading their precious seed on rocky and infertile soil.

Career advancement in most fields, but for certain in medicine happens via personal connections - networks rule the roost - and, that’s as good a rule of thumb as you’ll ever find in the career change game. You’ll get cold cuts from your cold calls. You’ll suffer the blues from your black hole experiences.

Read more about Networking here. Then, begin. It, like most everything worthwhile in life is difficult at first, but gets easier and more effective with time. It’s a sure-fire way to avoid the disillusionment of feeling rejected when the reality is nobody paid any attention at all.