In my last column, I offered advice about avoiding pitfalls as a student entering the medical school class of 2020. This week, I turn my thoughts to those entering residency and those beginning practice. Although these second and third stages of the journey toward life as a practicing physician vary by specialty, many of the experiences are common for all participants. These are pivotal transitions in a physician’s life. Learning how to perform surgery, make a complex diagnosis and independently care for patients requires a decade of commitment. Although it demands hard work, mastering the craft of medical practice should be extremely gratifying and fulfilling. But some aspects of this training process end up negative. Sometimes highly motivated, previously resilient individuals find themselves overly stressed, unfulfilled and experiencing some or all of the symptoms of “burnout,” from loss of motivation and lack of enthusiasm to frustration, exhaustion and cynicism. As I noted in the letter to medical students, half of all physicians surveyed across the nation report dissatisfaction with clinical practice. Much more seriously, it is estimated that one U.S. physician a day, or close to 400 per year, commit suicide. To avoid this destructive trajectory, it is essential for physicians at all stages of their training and career to take control of their lives. This is especially important when they face stressful situations like a resident’s 80-hour workweek and the early years of joining and building a practice. I believe that being a physician is the greatest of professions, and worry that many doctors today feel otherwise. Over the past decade, technology has undermined the doctor-patient relationship. Financial pressures have eroded the sense of purpose and mission. And the pace of practice has increased the sense of isolation and loneliness among physicians. We can ill afford to lose the equivalent of an entire medical school class each year to suicide. And we won’t solve today’s healthcare challenges if physicians are depressed and burned out. It is for these reasons that I write this letter. The advice I offer is personal, based on in-depth conversations with hundreds of physicians at all stages of training and practice. Through it, I hope to help physicians at these crucial junctures to develop resiliency to better manage the stressors they are likely to experience. In his remarkable book Man’s Search for Meaning, holocaust survivor Viktor Frankl speaks about the power of choice, purpose and resiliency. If he could overcome the obstacles he faced, surely we can in healthcare as well. And through that process achieve the fulfillment and tremendous joy that is possible through the practice of medicine. Dear Physician Colleague, To those of you who are new residents, the next several years will be incredibly exciting—you will learn much—but as you know, they also will be demanding. There is no shortcut to committing the hours needed to gain the mastery required for practice. You will inevitably go through periods during training when you will feel as though you have little control of your time. Much of your life will be dictated by others, especially your attendings and the needs of your patients. These are the times you need to take the best care of yourself, including eating as healthy as you can and maximizing the opportunities you have to sleep. As you know from your time as a third- and fourth-year medical student, sleep deprivation is frequent. I remember a dinner party I attended where my host worried when I did not return from the bathroom and found me fast asleep on the rug on the floor. The 80-hour-per-week limitation on residency training has eliminated some of the most egregious experiences with exhaustion. But adding travel to and from the hospital and required reading brings the time needed closer to 100 hours per week. Still, cut back the hours and you would need to train even longer, delaying completion. The tradeoff is a schedule that can be grueling and feel overwhelming. Delayed gratification is the reality of choosing to become a physician. I wish there were an easier path. Unfortunately, there isn’t. These constraints will increase personal stress. Indeed, depression affects 30% of people during training, raising the risk of burnout. My observation is that burnout arises when a person feels powerless, hopeless and unable to control any aspect of his or her life. And that feeling of powerlessness is psychologically painful. Ignoring it only makes it worse and puts people at greater psychological risk. Three Questions To Ask Yourself To help you avoid feeling powerless, and to maximize your fulfillment during this period of your life, I offer the following exercise. Take an hour or so to write by hand three letters to yourself, each less than a page and each answering a personal question. In the recently published book by Jonah Lehrer, The Book of Love, he points out the power of creating stories about your life. He advises using narratives to make sense of events and help address stress and anxiety. The following three questions, borrowed from others, are ones I’ve posed to myself along my journey. The first is, “What is most meaningful to you in your life?” Unless you’re conscious of what is most meaningful to you, you are at risk of losing it. For many it is friends and family, for others time spent volunteering, and for some passions like travel, art and music. Once you commit in writing to what provides meaning, you will need a plan to be sure you pursue and never lose it. The second question requires you to jump ahead in time to the end of your training, and to suppose that your life as a resident was as positive and rewarding as you hoped it would be. “What happened over that period of four, five or six years to make it so successful and fulfilling, both personally and professionally?” The third question is the converse. “You are at the end of your training, and you find yourself disappointed in the choices you have made and what you have accomplished. What went wrong?” As for those of you who recently finished residency, answer the same three questions looking five years into the future. And I suggest you repeat the exercise every five years, as your life evolves, to see whether you’re still on track and to map out your future. Three Key Precautions In training, you can’t control everything, but you need to stay vigilant and make your own mental health a priority. You’ll only be able to do a great job caring for patients if you take care of your own health. Here are some suggestions: Please get professional help if you experience any of the symptoms of depression or burnout. Your residency program will have resources. Invest in and value people, including fellow residents and others closest to you, to protect against the sense of isolation that can lead to burnout. You need personal interaction with those closest to you. Maintain the human connections and social networks in your lives. Ask your team members about their lives to show support; in return, they will give you the backup you need on demanding days. Identify the one or two most important people in your life, and schedule time with each, whether dinner with a friend or a date with a partner. Those who care the most about you understand how hard you are working and will avoid making additional time demands on you. Don’t let them. Get as much personal, human interaction as possible. Avoid dehumanizing your medical experiences. It is tempting to use medical shorthand and talk about the “appy in room six” and the “drunk in the ED.” Inside, you understand that both are real people, one with appendicitis and the other with a potentially life-threatening health problem. Language is powerful, and how you use it changes how you see the world. The entire residency experience tends to objectify people. Although these terms can feel time-efficient and essential for survival, they take a toll. Using them risks destroying what is most valuable about being a physician—the personal connection with people and high regard for human life. Now You’re A Doctor At last your resident training is complete. You’ve worked hard and made sacrifices, both financial and personal. I commend you for your dedication and commitment to others. Recognize that the hardest leg of the journey is over. Now is the time to restore your energy. You are finally, for the first time in a long while, free to increase your sense of control over your life and make your own decisions. Over the past decade you have earned the privilege of making choices. Now is your opportunity to do so. Please never forget that you have choices. The transition from training to practice presents a range of options—about where to live, whether to join a group or solo practice, and how many hours a day or week to dedicate to work. It is up to you to reach the decisions likely to bring you the greatest satisfaction. The act of choosing is the best defense against the feelings of powerlessness and being a victim that frequently lead to depression and burnout. My advice on your new choices: Take the time you need to decide about how your practice will affect your life. You may trade off time for money—only to discover that maximizing your income leaves you feeling less fulfilled. And if the first set of decisions you make leads to disappointment, remember you still have the option, however disruptive it might be, to pivot to a new practice environment. Read the answers you gave to the questions you posed to yourself as a resident about what means the most to you, and commit to making that central to what you do. See your story about finding fulfillment as a road map. Note why you made or failed to make certain choices and ended up unsatisfied, and take those warnings to heart. Bear in mind there never will be enough time, so prioritize the time you have, and do more of what is most important to you and less of everything else. Keep investing in the people you care about, whether family, friends or colleagues. Never stop doing this. It is too easy after others directed your life for a decade to be passive. In time to come, remember why you wanted to be a physician in the first place, and the reasons you selected the specialty you are pursuing. Celebrate the completion of the journey you set out on more than a decade ago, embracing the profession’s mission, purpose and values. Anticipate the decades of joy and gratification that now await you. And above all, take care of yourself, so you can be the type of healer to whom patients can entrust their health. Of course no one can promise you happiness, fulfillment and success. But by taking care of your own mental, physical and spiritual health—and by following the narrative you created for yourself—you can increase the probability of achieving all three. Sincerely, Robert Pearl Source
