A CRISIS IN AMERICAN MEDICINE By: Peter Moskowitz, MD
The practice milieu and the emotional profile and coping strategies of physicians are undergoing rapid change. There is growing and widespread career dissatisfaction. Increasing stress and burnout, medical disability claims, premature retirement, and alternative career planning by physicians are some of the secondary signs of this growing crisis in American medicine.
BACKGROUND:
PHYSICIAN CAREER STRESS: THE MATRIX FOR CAREER TRANSITIONS
The factors which physicians identify as being most responsible for their stress and dissatisfaction include a loss of practice autonomy, increasing hours of work, pressures to see more patients in less time, inability to control the work environment, loss of balance between work and private life, and decreasing financial rewards. More recently other factors contributing to physician dissatisfaction include the high cost of medical education and education-related debt, the high cost of home ownership in metropolitan areas of the country, and the changing practice and lifestyle expectations of younger physicians.
ADDITIONAL CAUSES OF MEDICAL CAREER TRANSITIONS
Other factors associated with medical career transitions include:
- Stress and burnout,
- Physical illness and disability
- Behavioral disabilities
- Skill-reward mismatches
- Expected vs. actual workload mismatches
- Academic advancement issues
- Generational / gender conflicts within medical groups,
For a more detailed discussion of these causes of medical career transitions, see reference
No. 1.
END OF CAREER TRANSITIONS (Retirement)
When physicians retire from the practice of medicine they go through a natural transition process that is highly variable and individually defined. This transition to retirement living may not go smoothly, particularly if a physician has no well-developed interests outside of medicine, or if their financial picture or physical health are not stable. Retirement works best when physicians have done extensive planning in advance, a process called, “protirement.” Such a plan is best done with the help of a career professional and a certified financial planner. Aside from needing a plan which meets the financial needs of the physician and his/her family, the retired physician needs a retirement plan which provides ample opportunities for finding personal meaning, a sense of contribution to society, new life challenges, and fun.
THE VALUE PROPOSITION FOR CAREER COACHING
Case History:
Dr. X, in severe burnout, made a decision to leave clinical medicine. It seemed like the only choice he had left. He couldn’t take one more day of his clinical practice. He had no idea what he wanted to do next. He therefore decided to seek career coaching. During the coaching process, he admitted that his decision to choose medicine was coerced by his father who threatened to disown him if he did not go into medicine.
“What did you want to do when you were 16?” I asked. “I wanted to go into TV and radio”, he replied. “What is stopping you from doing that now?” I inquired. A long silence ensued. Finally, he replied, “Come on, I have a wife and family! I can’t afford to leave practice, go back to school to get a degree in communications, lose two years of income, and then hope to find a job.” “Who said you had to do it THAT way?” I asked. Another long period of silence followed. “You mean there is an easier way?” he inquired. “There’s always an easier way,”I said.
Three years later, Dr. X had a radio show of his own at his local station devoted to health. He subsequently produced several outstanding programs for National Public Radio, and was in discussions to produce a health feature for his local Educational Television station. He was as happy as a clam, because he was finally doing what he had always wanted to do, and using
his medical career as a platform. He also rediscovered the joy of his clinical practice, although he had reduced his clinical effort to 75% time in order to have the time for his new career in medical communications. His burnout had resolved. He was happy, engaged, and loving both of his careers. His investment in career coaching had certainly paid off.
WHY WORK WITH A CAREER COACH?
. Career Coaches will support you with unconditional positive regard.
. Career Coaches understand where you are coming from.
. Career Coaches can help you do the Inner Work necessary for self-understanding. That Inner Work facilitates new OUTER WORK.
. Career Coaches can provide you with transition and networking resources.
. Career Coaches can save you vital time and shorten your transition time. Shortened transition time is saved money.
. Career Coaches hold you accountable to achieve your career goals.
CAREER THEORY:
THE THREE STAGES OF CAREER TRANSITION
The practical aspects of making a medical career transition can be divided into three stages: Waking Up, Taking Stock, and Taking the Leap of Faith. Note that this process is the same whether the physician is anticipating a transition out of full-time practice, a transition to a new full-time or part-time non-medical career, or simply anticipating a transition to retirement.
I. Waking Up
This first stage typically begins when physicians discover themselves in The Doldrums. This is not universally true; transitions can be initiated from any of the four phases of the career cycle. Once this reality sets in, the developmental tasks are to accept the reality and seek help. It will be important to do a brutally honest assessment of what has worked in the job and career and what has not; what is fun and what you hate. Then, one has to be willing to let go of what is not working or is hated, and hold onto what is working and enjoyable. This is an imperfect and impractical task, which can only be approximated. It will yield some temporary relief and improved clarity. It is important for the physician to decide what is reasonably under his/her control, and what is not. Then, be willing to let go of everything that is not. The age-old Serenity Prayer becomes useful: God, Grant me the serenity to accept the things I cannot change, power to change the things I can, and wisdom to know the difference.”
Expect to have powerful emotional responses in this first stage. Early in transition you may feel out of synch and strangely detached or lost. You will begin to question your entire professional role as a physician and question your relationships with other professionals in your field. This may be highly unnerving. You are not going insane, you are entering transition. William Bridges has described this stage as a time of Disengagement, Disidentification, Disenchantment, and Disorientation. You may also feel energized to be turning over a new leaf, leaving a frustrating position, or starting something new. You may also feel anxious and insecure about entering the unknown, about taking new risks. You may feel sad about leaving old friends and comfortable ways. All of this emotion may be confusing for the physician who has always been centered and self-confident. It is important to be aware that these experiences are common to all people in transition. Be conscious about these feelings. Allow yourself to feel them, recognize and name them. Talk about them with trusted friends and allies, coaches, mentors, therapists, and spouses/partners. Write about them in your journal. Pray and meditate about them in private. Unprocessed feelings otherwise may become roadblocks to success in the upcoming transition.
Those who give up familiar jobs, money, prestige, or clinical medicine for new uncertainty, lower pay, part-time work or retirement from clinical medicine may experience a series of feelings well characterized by Kubler-Ross as the Stages of Grieving. These stages include denial, anger, bargaining, sadness, and finally acceptance. These stages are not always experienced in this exact sequence, but completing the grieving process requires some experience of all of these feelings, processing them, and passing through them. Processing these feelings can best be done with a professional coach, mentor, or therapist. Expect them and learn to accept them as part of the process of transition as you move forward to the next chapter of your life. Once you establish a plan for the next chapter, and begin moving towards that vision for yourself, the uncomfortable feelings of the grief process will pass.
In this first stage of transition it is also important to acknowledge and celebrate what has worked. If there is to be a change in jobs, or leavings of any kind, plan a formal celebration event to remember the good things and the people who have helped make this job and your career a success. Endeavor to leave former jobs and colleagues with a positive memory. Acknowledge their contributions. Do your best not to burn bridges.
2. Taking Stock
The second stage of career transition is a time during which the physician is usually beginning to move out of the Doldrums, or has recently entered Cocooning. At this stage a number of important questions need to be asked and answered for the transition to move forward. Some of the questions are practical and relate to basic resources, others are more elusive, important questions which probe the very depths of your own self-understanding. These questions include:
Success in Stage 3., below, requires that the physician clearly identify his/her personal values, personal purpose, sense of calling, and their unique skills and abilities which have value in the marketplace. Answers to all of the above questions will prove to be critical in achieving happiness in the next life chapter. Using and integrating this knowledge of themselves, physicians eventually are able to craft a new vision for their career, or for retirement, which is
filled with passion, commitment, and is well integrated with their deeper selves.
Of all the questions, the ones pertaining to values, purpose, calling and meaning are the most important and difficult for the physician to answer. They are questions which probe the soul and the spirit of the individual, and for which there are no automatic right or wrong answers. Answers require time alone, to think and to reflect. Meaningful answers will come more easily to those who seek help from mentors, coaches, therapists, and family and intimate friends. Those who are successful learn to be patient and wait for the answers to become manifest. Rushing this phase of transition will usually lead to a poor career decision, one that is not consonant with your inner self.
Those choosing to cocoon will begin to do the self-exploring mentioned earlier and have lots of time to answer all of these questions. Those choosing the mini-transition will usually spend less time on the deeper questions, using the more practical questions to begin planning specific action steps to reengineer their work and/or obtain new skills/training.
What financial resources do I have available to assist me in transition? Are they enough?
Will they support a 3-6 month leave without pay?
If not, how much time can I comfortably take to work through my transition while still working? Do I need to work full-time, or can I reduce my clinical work to part-time?
What professional resources (e.g., career coach, therapist, mentor, accountant, financial planner, etc,) am I willing and able to make use of?
What non-professional sources of support can I make use of? (e.g., spouse, family members)
How old am I and how many more years do I need to continue to work? How many more years do I want to work regardless of income?
Do I have the support of my key loved ones? If not, how can I best go about getting it?
What is my calling in life? Am I following it?
What is really important to me, what are my specific values, what is my purpose, what am I passionate about? What are my marketable skills?
What aspects of work bring me joy and satisfaction, and what aspects of my work do
I hate and wish to give up?
What activities consistently yield personal meaning for me, in or out of the workplace?
How will I continue to find personal meaning, a sense of personal contribution, and personal connection to others once I retire from the practice of medicine?
What legacy do I wish to leave in this world?
3. Taking the Leap of Faith
The third stage of transition is the actual process of activating a plan for either a mini-transition, or a full-life transition, created in Stage 2., above. In this third phase, specific steps are initiated designed to propel you towards the future you envision for yourself. Action steps should be “SMART”. That is: Specific, Measurable, Achievable, Relevant and Time-specific. My experience is that physicians in this stage benefit from having a coach or mentor to help them formulate these action steps and help them stay on target and be accountable.
During both mini-transitions and full-life transitions, the physician can anticipate Stage 3. to be stressful. Therefore, first and foremost a sensible self-care plan must be in place. Ideally that plan includes regular aerobic exercise at least 30 minutes three days a week, at least 50 hours of sleep a week, a healthy diet, a program of regular spirituality, and time for friends and fun. Such a plan for life balance is the most powerful form of stress busting available.
Values-based time management and values-based money management should be instituted, with professional support, as needed. This may include a career/life coach, and/or a certified financial planner. New skills and learning will be undertaken, as appropriate.
Those who have been down this path successfully recommend that you engage in continuous learning, explore your fondest dreams and wishes without internal judgment or self-criticism, learn to ask for help, and finally, never look back! Above all else, transition is a spiritual path which requires a leap of faith, trust in yourself, and willingness to act despite your fear and inability to predict the outcome.
PITFALLS AND KEYS TO SUCCESS
In addition to courage, successful medical career transitions require the help of others, patience, and self-reflection. The latter three of these frequently pose a problem for physicians. A common pitfall is adhering to the John Wayne School of Medicine philosophy: “ I can handle this myself.” A good support network is critical, as well as skills in self-nurturing and self-care. Full life transitions by professionals require, on average, three years, although this is highly variable and can best be shortened with the assistance of an e effective mentor or career coach. In my experience, the most common pitfall encountered by physicians in transition is expecting themselves to do it too quickly and then regretting a too-quick decision.
There is danger in seeking a “quick fix”: Career transitions are typically not quick. Jumping quickly into an MPH or MBA program, or the hottest new consulting field, while tempting, may not be a suitable choice for you. Take the time to identify a new career path that reflects your personal values, interests, motivated skills, and personal sense of purpose or calling.
Avoiding activities which increase your self awareness is a sure prescription for a failed transition. Rather, look within and plan your new career from the inside out. Once you are clear about your purpose, career values, your unique skills, and passions, then set about to align this inner work with new outer work.
Don’t be in too big a hurry to leave clinical medicine. Many physicians I have coached initially wanted to leave clinical medicine, but subsequently found that addressing their issues with burnout and poor work-life balance successfully restored their enjoyment of clinical practice.
Finally, move forward despite your fear of the unknown, develop a willingness to let go of outcomes, and you can expect thrilling times ahead!
—
Peter Moskowitz MD, Center for Professional & Personal Renewal (Palo Alto, CA)
Peter S. Moskowitz, MD, Founder and Executive Director of the Center for Professional & Personal Renewal,
and Clinical Professor of Radiology at Stanford University School of Medicine, is widely recognized as a
leader in the field of physician career and life management, wellness education, and career transition
planning. A skilled career and life coach trained and certified at the prestigious Hudson Institute of Santa
Barbara, he has coached several hundred physicians and other healthcare professionals since 1996.
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