The myth of the ideal day for physicians

June 25, 2017

For physicians, the myth of the ideal day is a reality.

As the crow flies, their rooms in our rural hospital were less than 100 feet from each other, but their experiences couldn’t be more divergent.

In our labor unit, Emma was just hours from entering the world. Her parents, Valerie and Aaron, had diligently attended each prenatal visit and eagerly anticipated her arrival. Valerie’s labor was progressing smoothly, but it was clear that the delivery would drag on late into the evening. 

In the next hallway, our critical care unit, Arthur was preparing to enter eternity. For several years, his COPD had been inexorably advancing, requiring maximal medical therapy, continual oxygen and increasingly frequent hospitalizations. His family had repeatedly rebuffed discussions of end-of-life or hospice care, and though they agreed to honor Arthur’s clear DNR directive, they insisted we continue all therapies short of intubation. 

Then he presented in severe respiratory failure. Positive pressure ventilation, which had rescued him during several previous hospital admissions, was having only a marginal impact on his respiratory failure this time. His respiratory distress was worsening and agitation was escalating.

I was up most of the night adjusting his ventilation, carefully titrating his medications, trying to bring him some level of comfort without abruptly eliminating his respiratory drive. I met repeatedly with the family for lengthy discussions, trying to help them understand that Arthur would not rally this time and they needed to prepare themselves for his imminent death.

One family about to welcome a child. Another family unable to accept their beloved patriarch was not going to survive this hospitalization. And me, their attending physician, deprived of sleep and hungry for an evening with my family. It was a typical day.

I know what my ideal day looks like. I awake refreshed before dawn, read and write for inspiration, pray and meditate, play the piano, run a few miles as the sun rises and have an engaging discussion with my family over breakfast. At work, I attend the deliveries of all my obstetric patients (during daytime hours of course.)

I stay on time in clinic while keeping up with charting, phone messages and urgent care needs. I meet productivity, clinical quality and government reporting goals, while providing meaningful clinical and informatics leadership for our practice and our local hospital. I return home with adequate energy reserves, eat dinner with my family and am able to be fully present as we participate in our evening activities together. 

In over a dozen years of practice, how many days have followed this idyllic pattern? Precisely zero. But although individual days have their fair share of perceived disruptions, frustrations and disappointments, I have managed to maintain a sustainable degree of overall work-life balance following a few basic principles I return to over and over again. 

 

I accept I’ll never have an ideal day. Many of us in the medical profession are perfectionists. And while it’s good to strive for excellence, there are times we have to accept that something good, even if it falls short of our perfect ideal, is still worthwhile. 

When I finished residency, I realized I’d always wanted to play the piano. So I started taking lessons at the age of 30. In an ideal world, I would practice an hour or two every day and over the course of several years become fairly proficient. Well, it’s been over a dozen years of piano lessons, and I’m still a mediocre pianist at best. But I enjoy the process of learning new music, even if I’ll never perform at Carnegie Hall, and I’m committed to practicing daily. Most days I can’t manage an extended practice session, but I squeeze in at least a couple minutes, and accept that those few minutes are far more enriching than none at all. 

My family and I strive for life balance over the long term. My family understands that different days have different priorities. Some days Daddy stays at the hospital late with admissions and deliveries, but we balance that by dedicating other days and evenings to family priorities, like taking time off work for spelling bees and swim meets. This ensures that over the long term, we give adequate time and attention to all areas we consider important. 

We schedule our priorities. It’s often said that medical practice is a demanding mistress. And it’s true that if we don’t bloc time for the people and activities we consider most important, we’ll never get away from the tyranny of the urgent. On a weekly, quarterly and annual basis, my wife and I hold scheduling meetings. We decide which activities are most worth our family’s time, and which need to be pruned from the schedule. We schedule dedicated time for fitness, for romance and intimacy, for family activities and for travel. 

I trust my partners and sign out to them. I have the good fortune of having excellent partners with whom I share call duties. When I’m not on call, I sign out my laboring patients and hospital inpatients to them, so that my non-call evenings and weekends can be dedicated to my family and personal interests. 

I surround myself with excellent staff.  Our practice hires and retains excellent front office, nursing and mid-level provider staff. We empower them to function at their highest level of training, licensure and competency and trust them to do a good job. Surrounded by excellent staff, I can focus on duties that require a physician, and delegate all other tasks to staff who are equally competent and more available to do the same work. 

I get up ridiculously early and guard personal time against unimportant interruptions. No matter how ruthlessly I schedule things, I know I won’t get a chance to read for inspiration, play music or exercise regularly if I don’t do these things while most others are still snoozing. My most productive time is early morning, so I routinely arise by 4 or 5 a.m. to ensure I have time for these activities I consider essential for life balance, and don’t allow myself to do other less important things during that time. 

 

 

I regularly revisit my sense of calling. We all deal with burnout. Virtually all of us have days when we feel that all we do is push electrons in an electronic health record and swim upstream against a tsunami of patient noncompliance and self-destructive behavior, while our hands are tied by slow computers, pointless charting requirements and senseless prior authorization requests. I counter this by routinely revisiting my spiritual calling as a husband, a father, a servant in my faith community and a physician to adults, children and expectant mothers. For most of us, practicing medicine is more than just a paycheck. Regularly reminding ourselves of that vision helps keep the demands of our profession in perspective. 

Carpe diem. None of us is promised our next breath. In our profession, we’ve all seen people die tragically and unexpectedly. When the opportunity presents itself to do something fun or meaningful, I strive to seize the moment and enjoy it.