I recently called every member of my physician group as part of an effort to incorporate feedback on a group policy I was trying to develop.
I'm fortunate to work with folks I truly respect and admire, who collaborate and frequently ask one another to opine in challenging cases. In that spirit, I sought advice and suggestions from folks who would be germane to the policy as well as those who experience suggested might be skeptical of its value.
One of the unexpected aspects of my conversations was that a vocal minority physicians seem to believe that suffering is an inherent element of the physician experience. That without retaining some element of pain, you can't consider yourself a true member of your medical specialty.
I find this interesting, because I've come to enjoy my specialty of emergency medicine immensely more as I've eliminated aggravations. The notion that I'm less of a physician because my practice of medicine is less of a pain in the tuchus runs counter to personal experience.
Not feeling chronically depleted or burnt out has given me a second honeymoon with my specialty, and I love what I do more than I have in years.
The policy I'm designing is intended to address the drawbacks imposed by burnout and aging physiology by implementing a night shift differential.
It was implied by one colleague that by virtue of wanting to reduce my night shifts, I have no place working in emergency medicine. This struck me as odd.
I don't need to go through something I dislike in order to enjoy doing what I love. I don't need to dig out from several feet of snow after a freezing Boston noreaster, nor join my residency classmate in North Carolina piling sandbags last weekend to avert hurricane-related flooding, in order to understand that I thrive best in the direct sunlight of California.
Call me a dandy for where I choose to live? Sticks and stones. Call me a sucker for the price I pay for that privilege? Suit yourself.
But call me less of a physician for reducing obstacles that inhibit my ability to give my patients the best care I'm capable of providing?
Do my patients benefit from a more exhausted, less fit physician with poorer social supports? I beg to differ.
How much suffering is enough to satisfy the imaginary "certificate of mental toughness" others would insist is required to practice emergency medicine? I doubt there's consensus.
The initial ambivalence I felt about my chosen field was that it attracted a high percentage of cowboys and cowgirls. The first several conferences I attended for ACEP, one of our main specialty organizations, inevitably found me in a bar at 2AM listening to a couple of gunslinger residency directors boasting of how crazy their inner city urban knife and gun clubs had become.
Cute, I thought, brilliant (if insecure) docs who feel a need to put their balls or ovaries on public display to let everyone know just how brave they are.
With apologies to Shakespeare, Methinks they doth protest too much. I liked them as people, thought they were fun ambassadors for the field, but we didn't connect so well on a personal level.
What ultimately won me over to the field was that it also attracted a high number of the misfits of medicine, those people who were quirky but passionate and felt completely secure in their eccentricities.
While I liked the cowboys and cowgirls just fine, I really crushed on the musicians, birdwatchers, outdoor dirtbags, creatives and empaths for the downtrodden that were also drawn toward the shiny light of emergency medicine. It's their company that makes me feel a part of something special and exciting and unlike anything else in medicine.
Every specialty has its unique snowflake pattern of aggravations that reduce the joy of medicine and make you want to poke your eye out. No physician should be diminished for opting for a path, however nontraditional, that leaves her with sight preserved.
I'll take no offense if the world's great religions lay claim to martyrs.
But do me a favor. Don't expect me to bear your cross.
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Great post CD!
It really seems like we are ingrained with needing to show this “badge of honor” to others in our profession to somehow show our worthiness to practice medicine.
I remember in my fortunately brief stint in surgery residency how we would brag how many hours of sleep we got (the lower the better) or how many hours a week we were actually putting in (the higher the better, I recall a couple of times I was putting in 130+ hrs/wk for the month).
I think that is a game of one upsmanship that should be reserved fo the young. As I have gotten much older and wiser I realize that this has nothing to do with how good a doc I am or how well I provide patient care (in fact I think the opposite holds true like you implied, with lack of sleep and burnout contributing to decreased ability to provide good medical care).
I hope the burnout cry gains some footing. For the first time in my 12 years at my current job the president put out a letter saying they are looking into reducing burnout. That is a major step for the better in my opinion.
IMHO this is a result of an educational system where equality of outcome is confused with equality of opportunity. It’s the “every kid gets a trophy” turned on it’s head. Every Doc gets a sucky life because I have a sucky life and we must have equality of outcome or it’s not fair. My kindergarten teacher told me so. It’s part of the same raft of crap PoF got for his Business Insider article. How dare you turn your life into something satisfying and self sustaining, while I sit here and stupidly loath my existence. How dare you take a slot in med school without the commitment to bleed your eyes out for 30 years. In the end there is only one person you have to top, and that’s the you from yesterday. The rest can go pound sand.
Author
Gasem, I love the idea of an inverse trophy.
A favorite curmudgeonly attending back in the day used to have conniption fits and break into song over this very idea, claiming modern med students were stunted from being taught to sing: “Nobody else has feet like mine, feet like mine, feet like mine, nobody else has feet like mine, I’m SO special.”
Nowadays, everyone wants me to have feet like theirs.
Thanks for the fresh perspective, my friend.
In my group we had a mix of players. I created a group norm
such that if you were going to work for me you HAD to be satisfied with 90% of what you wanted, and I told them that on the first interview. If you started angling for 92% you could go find another job. The reason is about 10% friction is what a group can tolerate. When someone wants 92% it means everyone else starts feeling shafted, even though the shafting my be trivial the group psychology goes to hell. The job was a good enough job and people understood how things worked so I had pretty low turnover and pretty good cohesiveness. The other thing was NO KINGDOM BUILDERS. If you get some joker typically someone pretty proud of his intellect who’s hellbent on becoming king the whole shootin match blows up.
Gasem:
-Yes!
Can you get my group to implement a night shift differential? 7 years ago I wouldn’t have sacrificed a penny to get out of nights. Now I’ve found enough alternative income streams that take place during banker’s hours to afford the hit.
Patients don’t benefit from tired burnt out docs. Sleep deprivation has never once made my skills sharper or helped with my empathy.
Not wanting to work nights doesn’t make you less of a doc – it makes you a sane human capable of rational thought.
I also loved the fact that the ED is the land of misfit toys. There’s dozens of reasons people choose EM and I like how all the personalities gel.
Author
SHS,
Time heals all desire to work nights. Should I encounter success, I might just post on it – but the wounds need to be less fresh to do so comfortably.We have a terrific crew, and I am cautiously optimistic that they will come around with time.
As for the misfit toys – I wouldn’t trade my dysfunctional family for any other.
Appreciate your support!
“It was implied by one colleague that by virtue of wanting to reduce my night shifts, I have no place working in emergency medicine. This struck me as odd.”
Hi, CD,
We are kindred spirits, in many ways. I have benefited greatly from reducing my work commitment to 60%. (In fact, an old friend at a gathering at our home last night was gushing about how great I look, which I attributed to my part time status.)
I also have no interest in working nights. I expect to sleep in my bed, the fitful 5-6 hours that my dogs, my mind and body will allow.
What invariably comes up in these partner discussions, depending on the age range of docs, local sports teams’ success, DJIA, and relative motivation of the partners, is that someone must be available to work these undesirable shifts (our Sat-Sun weekend pull). We have generally split them equally, with part timers taking a proportional share. Everyone shares the pain.
I have said for years, maybe even decades, that there should be an opportunity for sanctioned opting in/out of these shifts. If we were to value these shifts in monetary terms, such that there is an equilibrium of people willing to take them vs. skip them, we might allow people that need more money to earn a little more and those of us who value time and recovery to pass.
I hypothesized that if we valued a weekend of work at $250, no one would sign up for it. If we valued a weekend of work at $25,000, people would be fighting tooth and claw to work them. Somewhere between the two, there is a number where most partners will just choose to work them and on the fringes, a few weekends will change hands between those not wanting to work and those wanting to work extra.
Keep fighting the fight to work less, better, and smarter. I will back you up.
Best, VBMD
Author
My hope is that our group adopts a free market plan that makes nights into an asset by which motivated group members earn a compelling premium above their standard compensation, so it’s all carrot and no stick (exactly as you envision). Those who want increased income or a reduced workload are empowered to achieve it (You mean I can work 7 nights instead of 5 days plus 5 nights and make the same income? Sign me up!).
Those have reached enough, whether by limits imposed from aging physiology, frugality, or values that prioritize escaping nights can opt out and pay dearly for he privilege.
Gasem’s eloquently described “equality of misery” mindset will be a hard tradition to buck, but I plan to give it my best shot.
Thanks for having my back, Vagabond.
Gradually, the whole paradigm of medical martyrdom will be turned on its head. Especially with the millennial generation having a different perspective on work. They want work to be built around their lifestyle, not the other way around. And I think that’s great as long doctors do a good job and are dedicated to their patients. Why is pain and suffering so necessary? Doesn’t make sense to me.
Hi CD,
My husband trained later as a surgeon after a stint in family practice. By the time he was qualified, I was almost FIed.
He started right out of the gates taking a month off every summer. Luckily no one really noticed, they just traded their call duties. It is harder to do within a solely hospital based group I suppose.
The fact is some of his colleagues gradually realized that he did not want to keep doing call. So for about a decade, he was able to get rid of almost 80% of his call to locums and other colleagues.
He ended up being very surprised by the number of his colleagues who would quietly ask to work his call shifts.
We certainly have never participated in group think and do not believe in martyrdom.
I have worked calls every second day and would never want to wish that on anyone.
I believe evening shifts should always have a built in monetary incentive.
Author
Dr. MB,
Your husband’s situation illustrates that a positive incentive (as opposed to an equally apportioned dread) can make all the difference between allowing individuals to meet their goals and depriving all parties of their objectives.
In Animal Farm, George Orwell gave us, “All animals are equal, but some are more equal than others.” There are medical groups that function with this type of exploitation, and I’m fortunate not to work in one.
Medicine has given us, “All creatures should be equally miserable.”
I’m hoping that by making the financial incentive both sufficiently compelling and voluntary, docs who volunteer will end up feeling handsomely rewarded for taking on less desirable shifts reducing the potential for resentment.
Thanks for the most illuminating anecdote – you give me hope.
Fondly,
CD
Great post Crispy Doc. You and I have much in common. I have a senior leadership role in our physician group and tackled this exact issue over the past 5 years. The first time unsuccessfully, but starting the conversation for success in the second round.
I practice ICU in an academic hospital. There have always been gaps in the inhouse resident night schedule. A small group of us younger attendings filled them in. However, we were all now older and needed to spread the load. The choices were that everyone does an equitable share of nights or the nights get a premium by taxing the daytime docs. Doing nights would have been physically very hard for some of our senior and most academically productive faculty. So, we went with a taxation system to achieve a 25% premium for the night docs from the days. You do your share of nights, you are even. Work more nights, make a bit more. Skip your nights, and make a bit less. Those outside of our group thought we were crazy, going to destroy academic medicine, going to worsen burn-out, etc. etc.
A couple of years later, no one here would go back to the way it was. In fact, it is seen as the best change we have ever made. Those who are work-machines and want money get what they want. Those who have money and want time are happy. This ability to self-select fits more naturally with the individual “attending lifecycle”. Our academic output is up because people’s work doesn’t halt for a full week while on service.
Burn-out is palpably better, translating into improved and more compassionate patient care. The more freedom physicians in a group have to shift around their workload as their lives and bodies change, the more we will reduce burn-out. The sense of lack of control to change your work-life is a contributor to burn-out and this removes that in one way.
Don’t give up on it. It takes time for physicians to grapple with their biases and adjust, but most after being challenged and reflecting do. It took us a few years but was well worth it.
-LD
Pride about how aweful and our schedules can be is a defense mechanism for the torment some people have to go through. Either you can lament and be down trodden about your 90hr week or you can turn it into a source of pride and glory. Turn into a measure of your worth as a physician in that field. To be in that spot must suck.
Working overnights feels terrible and I am glad don’t have to and grateful to those who do.
We force these insane schedules on ourselves and the culture of medicine says we must bear it and not complain.
But this is slowly changing. Life is more than medicine and nearly everyone I trained with would gladly work “just” 40hrs a week.
Goodluck making changes at your job!!
I would of gladly accepted less money for no nights when I was doing OB. I was totally crazy and burned out with my first job out of residency. The attitude was suck it up. As a new member of the group I was on call Thanksgiving and Christmas. I do not know how I survived for 4 years. I just did not know any better. I think the millennial generation is going to end martyrdom. It is about time.
Awesome post! Night shift differential should be an extra hour pay-bare.minimum! DH did nocturnist for almost a year and a half and the “pay off” beyond that was “pick your schedule”-until someone decided that wasn’t “fair”…so we quietly paid off the renovations debt and he quit that gig. Pick your battles, but always have options waiting in the wings should the game change…#FI #FIRE