You’ve probably heard the story of a traveler who arrived in a bustling medieval town, dusty and worn and looking for work. He made his way to the center of the town, where he found a group of men in what appeared to be the early stages of constructing a building. “What are you doing?” he asked the first man he encountered. “I’m laying one stone on top of another. What does it look like I’m doing?” snarled the man, barely looking up. Taken aback, the traveler approached another man and posed the same question. “I’m making money so I can put bread on the table and a roof over the head of my family,” this one said, his voice heavy with exhaustion. Unsatisfied, the traveler asked one more man his question. This time, the man raised his eyes toward heaven and with obvious pride in his voice said, “I’m building a cathedral.” How wonderful it would be if we could see our role as family physicians in such transcendent terms; if we could always experience the joy of doing something so filled with meaning. In reality, however, we all experience times when our work feels like sheer labor.
“Life would be simpler if I didn’t have to contend with ___________.” We could fill in the blank with almost anything about our practice environment – HMOs, diagnosis coding, credentialing. At times, it does seem that external forces randomly tinker with the equilibrium of our lives. But the truth is that our happiness and sense of well-being are largely independent of forces from our outer world and more dependent on the forces of our inner world – how we choose to interpret things and what course of action we decide to take. While we may have little control over external forces, we do have the power to mold our thoughts and shape our actions in ways that can greatly enrich our lives.
Several years ago, my reading of Thomas Moore’s Care of the Soul: A Guide for Cultivating Depth and Sacredness in Everyday Life led me to the eye-opening notion that our work, in addition to being a source of income, pride and intellectual challenge, could be a source of joy. (Also see the reading list.) Though I certainly have dry spells when what I do seems like piecework on an assembly line, more and more often I have moments where the world fades away and there’s nothing in the room but a patient and me and the work we’re doing together. I have found that cultivating this joy requires a mixture of techniques borrowed from Eastern and Western traditions. Many are ancient but no less useful for us in the 21st century.
Most people go through the day on autopilot, doing routine tasks without much thought. This can cause people to lose touch with themselves and the world around them.
To derive more satisfaction from medicine requires staying focused on the present, giving up the quest for perfection and being more accepting of yourself.
It also requires determining for yourself the meaning of your work and looking beyond the day-to-day tasks to realize the greater good that you do.
Here and now
To derive greater joy from our work, we must learn to be in closer touch with our immediate surroundings. The idea seems so simple, and yet it is difficult, because our minds are not used to staying focused. Even when we try to concentrate, our thoughts are pulling us in different directions – wondering about a certain patient’s lab work, rehearsing what we plan to say to a consultant, trying to remember the source of a particular article that caught our eye, reliving a conversation with the family of a hospitalized patient, thinking about our child’s baseball game.
According to Jon Kabat-Zinn, PhD, head of the Stress Reduction Clinic at the University of Massachusetts Medical Center, most of us go through each day in a state of “automaticity” that resembles an extended dream state more than wakefulness.1 We have a tendency to either dwell on the past or look toward the future. We also function on autopilot much of the time. We go about our routine tasks without much thought. These habits leave us out of touch with ourselves and the world around us, causing us to feel chronically, vaguely unsatisfied. We miss the beauty that surrounds us every moment – the smile on the face of a loved one, the warmth of the sun on our skin or an uplifting passage of music – all because we aren’t paying attention.
While it’s true that we will never achieve complete mindfulness at all times, we can increase these periods through regular practice. There are a wide variety of exercises to choose from (see “Staying focused” for a few examples). In the Buddhist tradition, a bell is used as a call to the present. In my practice, the ritual of taking a patient’s chart out of the rack just before I meet the patient serves as my “bell.” When I reach for the chart, I clear my mind of competing thoughts (other patients, tasks, my family) and focus completely on the present. I look at the patient’s name, the vital signs, the reason for this visit and the most recent previous visit. Then I offer up a brief prayer asking that I be an instrument of help for this person. Perhaps you have a similar ritual you can cultivate that reminds you to be present for each patient you see.
For me, mindfulness creates a richness in the one-on-one patient interaction, making me more alive to the whole encounter. And more important, I am focusing my entire attention on the patient, which makes me a better doctor.
Seize the day
To derive greater joy from our work, we must make the most of each experience. When was the last time you became so involved in an activity that nothing else seemed to matter? Have you ever had an experience so enjoyable that you would do it even at great cost for the sheer sake of doing it? Mihaly Csikszentmihalyi describes such events as “flow” or optimal experiences. We have a sense of control over our actions and a feeling of exhilaration with optimal experiences. These experiences come “as close to what is usually meant by happiness as anything else we can conceivably imagine,” according to Csikszentmihalyi.2
For us as family physicians, optimal experiences occur when we feel so involved in the patient encounter that the rest of the world seems to fall away. Seizing opportunities for such experiences makes the whole practice of medicine seem worthwhile, and patient care is at one of its better moments when we are so wrapped up in delivering the best care possible.
According to Csikszentmihalyi, optimal experiences are something that we make happen. We can set the stage by creating goals for ourselves. When we decide on our own goals rather than leaving that to some outside entity, there is great satisfaction in working toward them. Of course, we will always have other people’s expectations to contend with, but perhaps we can take external expectations more in stride if we are also working to achieve our own objectives – whether it’s trying to do a simple task better, learning a new procedure, increasing the percentage of patients who meet health maintenance recommendations or mastering a difficult subject.
The ability to interject creativity into our work also contributes to flow. Consider the many options for treating headaches, depression, hypertension and such – pharmaceuticals, lifestyle changes and cognitive therapy. With so many options, I get a great deal of pleasure working with each patient to come up with a treatment plan that is right for that patient. I like to listen for that little voice within me that sometimes tells me to try something new or to apply something that worked in another situation.
Nobody is perfect
To derive greater joy from our work, we must be willing to accept both our strengths and our weaknesses. Most of us got where we are today by being high achievers, pushing ourselves harder and harder. We are in a specialty where the breadth of what we are supposed to know is huge. We secretly fear that if we don’t push ourselves to be perfect diagnosticians, our work will become shoddy. We think we could get a little closer to perfection if we remembered things better, if we kept up with our journal reading more or if we picked just the right continuing medical education. We compare ourselves to others who, we fear, may be farther down the road of perfection than we are. Rather than following our own instincts about the best patient care, our decisions are unduly influenced at times by what we think someone better qualified might do.
A wide variety of exercises can help heighten our awareness, keep us focused and release tension. The following are a few examples.
Set aside time for regular meditation, preferably in the morning. One approach to meditation is a deep breathing exercise. Sit or lie in a comfortable position. Clear your mind of thoughts and focus your complete attention on your breathing. (If thoughts do pop up, rather than fight them let them float in and out and then return to concentrating on your breathing.) People who have done this exercise regularly over the years have found that it increases their mindfulness far beyond the 20 to 30 minutes they devote to it in the morning. It lasts well into the day.
Try concentrating on a particular sense throughout the day. If you choose vision, really look at things. Concentrate on the beauty of what you see. If you choose hearing, tune into the sounds around you. Pay closer attention to the stories your patients want to tell you. If you choose touch, be aware of the power of the healing touch in your work.
Devise a signal that alerts you to do an attitude check. For example, the next time your pager goes off, don’t answer it instantly. Instead, take three deep breaths and then smile. Smiling actually diminishes tension. Then think about the phone call positively. Think of it as an opportunity to connect with another person and to use the wonderful knowledge you have been given. (This exercise is adapted from a phone meditation suggested by Vietnamese Buddhist monk Thich Nhat Hanh.)
Take advantage of instant stress relievers. If you’re feeling stressed, try taking six deep breaths, visualizing a favorite place, stretching several times or taking a short, brisk walk.
As long as we cling to the idea that perfection is attainable, frustration and disappointment are always around the corner. The desire for perfection keeps us distracted and always judging ourselves, so we often don’t really hear what our patients, our staff or our families are telling us. And, if we’re not careful, the unrealistic demands that we place on ourselves lead to cynicism, poor rapport with patients and, eventually, job burnout.
So how do we balance our desire to be good physicians with our inclination to be perfectionists? It’s a matter of self-acceptance, recognizing that we do have special skills and gifts, while acknowledging that there are some things we don’t do as well as we would like. It is a sense of being grounded that comes with some experience – the realization that we can take care of any patient that comes to us and that when we do need help, we know where to find it. With this awareness, we are better able to respect the skills of our colleagues while appreciating our own strengths. We are also better able to hear what our patients are telling us. When I gave up the notion that I had to figure everything out, I was able to relax and listen to my patients. I have found that patients have a lot of wisdom about what they need or want and, a lot of times, they’ve got some good ideas.
In giving up the quest for perfection, I find I am able to do things more easily. I am more likely to remember those chance things I came across recently that will help a particular patient. It may be an article I read last week or an approach I learned from a discussion I had with a therapist six months ago. It’s the Zen paradox at work. It’s when we give up trying so hard that we do our best work.
Give yourself a break
To derive greater joy from our work, we also must learn to exercise self-compassion. For most of us, compassion is why we chose family practice in the first place. But sometimes we channel all of our compassion to others and none to ourselves. By cultivating compassion for ourselves, we develop the confidence and sense of well-being to forge ahead in our work and to relate to our patients with greater empathy and better understanding.
We can greatly reduce our anxieties by learning to be more patient with ourselves. I have always hated Advanced Cardiac Life Support recertification because emergency medicine isn’t the kind of medicine I like. When I returned for recertification this time, however, I coached myself and developed personal affirmations (positive statements about me and my abilities). I told myself, “People with less training do this. You are working yourself into a state. Be calm and accept it. Don’t get tense. This will be a pleasant experience.” Lo and behold, it was a good experience, and I performed very well!
We must also learn to be more tolerant of our mistakes. Nobody is perfect. Instead of beating up on ourselves, we should apply cognitive therapy – exchanging bad thoughts for more positive ones. The thought becomes, “I accept that I made a mistake. This is an area I will focus more attention on.” Many of us teach this approach to our patients all the time, and it’s one we can use as well. By smiling at our foibles and mishaps with the same humor we use with our children, our own well of compassion becomes replenished, and we have greater kindness and patience for all who cross our path – our staff, our loved ones and even our difficult patients.
The Reinvention of Work: A New Vision of Livelihood for Our Time. M. Fox. San Francisco: Harper San Francisco; 1994.
Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. J. Kabat-Zinn. New York: Hyperion; 1994.
A Path With Heart: A Guide Through the Perils and Promises of Spiritual Life. J. Kornfield. New York: Bantam Books; 1993.
Care of the Soul: A Guide for Cultivating Depth and Sacredness in Everyday Life. T. Moore. New York: HarperCollins; 1992.
Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. J. Kabat-Zinn. New York: Dell Publishing; 1991.
Peace Is Every Step: The Path of Mindfulness in Everyday Life. T. Nhat Hanh, A. Kotler, ed. New York: Bantam Books; 1991.
Flow: The Psychology of Optimal Experience. M. Csikszentmihalyi. New York: Harper & Row; 1990.
The Relaxation Response. H. Benson, M. Klipper, ed. New York: Avon; 1976.
The search for meaning
To derive greater joy from our work, we must be able to look beyond mundane tasks and day-to-day hassles to the greater good we do. Occasionally, we have all probably had experiences that beat us down or days when our work seems just plain dull.
It has been said that all work contains drudgery; the issue is whether the work holds meaning. Most of us went into medicine because of a belief that we could help people. Perhaps we imagined we would effect great cures. In our real practices when we see that people don’t always get well or aren’t always grateful, we may become cynical at times. We may doubt that our work has meaning after all. Or we may feel like mere minions of some large, impersonal system.
FINDING VALUE IN DAILY ROUTINE
If you feel you’ve lost touch with the importance of your work, try one or more of these simple exercises. Each activity is designed to heighten awareness of your contributions.
Keep a journal for several weeks. Take a few minutes each day to write about your experiences. Over time, you will gain a broader perspective of the impact you are having on other people’s lives.
Place thank-you notes you receive from patients and their families in a small file box on your desk. When you’re feeling discouraged or have a particularly trying day, take time to read several of these notes.
Select something rather mundane that you do many times each day, like writing a prescription or auscultating a heart. For one week, pay closer attention to the way you do that activity. More than likely, you will be reminded that what has become mundane is actually a remarkable process.
Try treating each patient you see as if he or she were sent to teach you something important. Think how that would change the tone of your usual office visit.
How do we find meaning in the midst of the adverse aspects of medical practice? We must determine for ourselves what the meaning of our work should be rather than leaving that exclusively to outside entities. Finding meaning within ourselves is certain to inject a reverence for what we discover we were called to do.
We can move beyond the daily worries that haunt us by focusing more attention on our contributions to society. Kabat-Zinn relates the story of Buckminster Fuller’s suicide attempt when he made the fateful decision to live from that moment on as if he had died that night. “Being dead,” Kabat-Zinn wrote, “he wouldn’t have to worry about how things worked out any longer for him personally and would be free to devote himself to living as a representative of the universe. The rest of his life would be a gift. Instead of living for himself, he would devote himself to asking, ‘What is it on this planet that needs doing that I know something about that probably won’t happen unless I take responsibility for it?’”1 We, too, must learn to focus on the bigger picture.
We must also stay alert to how changes in the health care system affect family practice and be ready to adapt to new and different demands. What may be called for is a new way of seeing our work in the 21st century. While we will always be dealing with the effects of disease-fighting idioms, we need to make room for idioms that speak more to cultivating health. For example, we can broaden our definition of health promotion beyond cholesterol checks and tetanus shots (as important as those are) to include teaching ourselves how to motivate our patients to adopt healthy lifestyles.
Finally, we can take comfort in knowing that our contributions are recognized and appreciated. Many simple exercises can help us remind ourselves that our efforts do not go unnoticed. (See “Finding value in daily routine.”)
We are practicing in a time of tremendous changes and increased demands. If we allow ourselves to be unduly influenced by external forces, we can easily lose sight of what is important. We must remember that it is our inner world that keeps us grounded. By taking a few simple steps to enhance our self-awareness, we can gain new insight about ourselves and our work and renewed enthusiasm for the practice of medicine.